^'c; 


^1 


-0fi4 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETT 


November 


THE  THERAPEUTICS 


RESPIRATORY  PASSAGES 


PROSSER   JAMES,   M.D., 

LECTURER    ON    MATERIA    MEDICA   AND   THERAPEUTICS   AT  THE   LONDON   HOSPITAL   MEDICAL   COLLEGE  ; 

PHYSICIAN    TO    THE     HOSPITAL     FOR    DISEASES    OF    THH   THROAT  AND   CHEST;    LATE   PHYSICIAN   TO 

THE    NORTH    LONDON     CONSUMPTION     HOSPITAL  ;    CONSULTING   PHYSICIAN   TO  THE   CHILDRENS' 

HOME    INFIRMARY,     VICTORIA     PARK  ;    CORRESPONDING     MEMBER    OF    THE     ACADEMIES    OF 

MEDICINE   OF    LYONS,    MADBID,    AND   BARCELONA,    ETC.,    ETC.,    ETC. 


NEW  YORK 
WILLIAM    WOOD     &    COMPANY 

56  &  58  Lafayette  Place 

1884 


Copyright,  1884, 
Bt   WILLIAM   WOOD   &  COMPAIfY 


TROWO 

PRINTING  AND  BOOKBINDING  COMPANY, 

SEW  YORK. 


Biomedical 

Library 


I40 


PREFACE 


This  book  is  not  intended  as  a  manual  for  students — it  is  lioped,  in- 
deed, that  senior  students  as  well  as  practitioners  may  peruse  it  with 
profit — but  it  is  mainly  intended  for  those  who  have  left  the  schools 
and  entered  upon  the  responsibilities  of  practice.  Such  readers,  hav- 
ing no  longer  the  fear  of  examiners  before  them,  may  be  interested  in 
points  upon  which  they  would  not  otherwise  dare  to  spend  their  time. 

Xo  doubt  many  faults  will  be  found  by  critical  readers,  but  not 
more  than  those  of  which  the  writer  is  sufficiently  conscious.  Some 
portions  may  be  found  too  diffuse,  others  too  condensed,  and  those 
who  only  refer  to  a  question  here  and  there  may  fail  to  see  the  con- 
nection between  them,  or  perhaps  to  find  that  which  they  seek, 
Tliose  who  read  the  book  through  will  not  fail  to  discover  the  thread 
on  which  I  have  strung  my  beads — observe,  I  do  not  call  them  pearls. 
But  as  few  may  do  this,  it  may  not  be  amiss  to  say  that  there  is  a  dis- 
tinct purpose  in  the  work,  and  it  is  with  "  malice  aforethought "  that 
some  portions  have  been  so  extended  and  others  so  contracted. 

Such  as  it  is  I  commit  this  production  to  the  candid  consideration 

^  . 

■S:  of  my  professional  brethren,  who  have  heretofore  received  my  writings 
'v. 

V   with  so  much  favor. 

rs, 

•^  Pkosser  James,  M.D. 

3  Dean  Stueet,  Pakk  Lane,  London. 


October,  1884. 


624331 


CONTENTS. 


CHAPTER  I. 

PAGE 

Introductory 1 


CHAPTER  n. 

Nutrition  in  Relation  to  Therapeutics 3 

CHAPTER  m. 
Respiration 14 

CHAPTER  IV. 

Food  and  Diet — The  Proximate  Principles  of  Foods— Food-stuffs.  ... .     21 

I. — Nitrogenous,  Plastic  or  Albuminous  Foods,  22  ;  II. — Xon-Nitrogenous,  2'd  ; 
III.— Inorganic  Substances,  24  ;  Nutritive  Value  of  Foods,  26. 

CHAPTER  V. 

Preparation  of   the  Food-stuffs — Digestive  Fluids 32 

Saliva,  33  ;  Gastric  Juice,  34  ;  Pancreatic  Juice,  30  ;  Bile,  37  ;  Succus  Enteri- 
cus,  38. 

CHAPTER  VI. 

Variations  in  the  Digestive  Process 3!J 

A.— The  Body,  40  ;  B.— Aliment,  40. 

CHAPTER  VII. 

Aliments  as  Remedies — Nutrients  and  Anai,eptics 44 

Promoters  of  Construction,  45. 


VI  CONTENTS. 


CHAPTER  Vm. 

FAOE 
1  KON 56 


CHAPTER  IX. 

Phosphorus  and  its  Compounds  C4 

Free  Phosphorus,  68  ;  Hypophosphites,  73. 

CHAPTER  X. 

Aids  to  Digestion 74 

Stimulants  to  Digestion,  78. 

CHAPTER  XI. 
Tr.anspusion 79 

Injections  into  Serous  Cavities,  82  ;  Hypodermic  Injections  of  Blood  and 
Food,  83. 

CHAPTER  XH. 

Water — Diluents — Beverages 85 

Beverages,  89. 

CHAPTER  Xin. 
Exercise  and  Rest 94 

CHAPTER  XIV. 
Alcohol ' 97 

CHAPTER  XV. 

Denutrients 107 

Antiphlogistics,  107;  Bleeding,  109;  Counter-irritation,  117;  Evacuants. 
119  ;  Mercury,  121  ;  Diaphoretics,  133. 

CHAPTER  XVI. 

Antipyretics 143 

Cold,  145;  Quinine,  157;  The  Salicyl  Compounds:  Salicin,  Salicylic  Acid, 
and  the  Salicylates,  166  ;  Kairin,  171  ;  Chinolin  or  Quinolin,  174  ;  Eesor- 
ciu,  174  ;  Veratria,  174  ;  Digitalis,  175;  Aconite,  177. 


CONTENTS.  Vll 

CHAPTEE  XVn. 

PA'K 

Neurotics 187 

Narcotics,  187. 

CHAPTER  XVm. 

Pneumatics 208 

Expectorants,  213  ;  General  Expectorants,  222;  Antiseptic  and  Disinfectant 
Pneumatics,  249  ;  Antispasmodic  Pneumatics,  255  ;  Sedative  and  Anodyne 
Pneumatics,  262  ;  Contra-Expectorants— Central  Pneumatics,  263. 

CH^iPTER  XIX. 

Topical  Pneumatics 276 

Methods  of  Inhaling,  282  ;  Uses  of  Inhalations  and  other  Topical  Pneumat- 
ics, 294  ;  Solids,  303. 

INDEX , 309 


THERAPEUTICS 


RESPIRATORY    PASSAGES. 


CHAPTER  I. 
INTEODUCTOEY. 


The  word  therapeutics  is  often  used  in  much  too  restricted  a  sense. 
It  is  derived  from  Oepairevoi,  which  is  commonly  translated,  I  cure,  but 
which  is  susceptible  of  a  far  wider  signification.  It  may  be  fairly  ren- 
dered, I  take  care  of,  or  render  service  to  (the  sick),  and  thus  includes 
whatever  relief  to  suffering  or  help  to  restoration  may  be  conferred. 
Thus  the  therapeutist  is  the  medical  attendant,  not  the  mere  prescriber 
of  more  or  less  potent  medicines.  His  materia  medica  includes  all 
those  materials  which  may  be  pressed  into  medical  service.  Thus  it  is 
as  much  his  business  to  remove  an  accumulation  of  fluid  from  the  pleura 
by  means  of  the  aspirator  as  to  promote  its  absorption  by  the  lymph- 
atics, and  the  instrument  is  as  much  within  his  use  as  a  remedy  as  the 
administration  of  the  often  inefficient  absorbents.  To  apply  a  bandage 
or  a  splint,  nay,  to  fashion  one  from  any  material  at  hand  is  as  much  a 
therapeutical  proceeding  as  to  order  a  poultice  or  prescribe  a  narcotic. 
Nor  is  this  a  novel  doctrine,  for  during  the  thirteen  dark  centuries 
which  followed  Galen  every  one  admitted  the  importance  of  the  "non- 
naturals,"  as  they  were  called  by  the  Peripatetics,  and  we  know  that 
long  before  him  these  subjects  were  ably  treated  by  Hippocrates,  to 
whom,  indeed,  Galen  looked  up  with  reverence,  and  whose  method  he 
did  much  to  revive,  avowedly  taking  him  as  his  guide,  although  it  must 
be  admitted  that  he  was  sometimes  led  away  by  the  unsubstantial  specu- 
lations of  the  dogmatists  who  repudiated  for  empty  hvpothesis  the 
1 


2  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

solid  result  of  the  patient  and  attentive  study  of  nature  inculcated  by 
the  sage  of  Cos.  These  non-naturals  are  commonly  defined  as  the  prin- 
cipal things  which  do  not  enter  into  the  composition  of  the  body,  but 
are  nevertheless  necessary  to  its  existence.  Galen  called  them  the  pro- 
catarctic  causes,  TrpoKarapKTtKos,  principal,  from  -jvpo,  and  Kara  and  dpxofJiai, 
I  befin.  He  considered  that  when  well  used  and  properly  disposed 
thev  contributed  to  the  health,  but  otherwise  to  the  derangement  of  the 
system.  They  are  air,  meat  and  drink,  exercise  and  rest,  sleep  and 
wakino-  retention  and  excretion,  and  the  passions  and  affections  of  the 
mind.  But  lonf  before  the  Hippocratic  writings  laid  such  broad  foun- 
dations for  Greek  medicine  the  importance  of  such  subjects  had  at- 
tracted the  attention  of  the  sages  of  earlier  civilizations.  Thus  we  find 
diet  and  reo-imen  treated  of  in  the  oldest  records  of  Hindoo  medicine. 
These  are  written  in  the  most  ancient  form  of  Sanscrit,  and  are  be- 
lieved to  extend  from  the  third  to  the  tenth  century  before  the  Chris- 
tian era.  The  Buddhists,  too,  have  records  of  early  thoughts  on  these 
subjects,  on  which  even  ancient  Chinese  literature  is  not  destitute  of  ad- 
vice, overlaid  though  it  undoubtedly  is  with  accumulations  of  the  strangest 
and  most  preposterous  fancies.  But  it  is  not  worth  while  to  pursue 
this  subject,  for  it  is  obvious  that  the  effects  of  food,  air,  and  other 
agencies  would  be  observed  by  ever}'  race  quite  as  early  as  the  influence 
of  medicinal  plants,  and  we  know  that  the  observation  of  such  influences 
dates  from  the  remotest  times,  while  scarcely  a  savage  tribe  is  known 
but  possesses,  either  as  a  treasured  secret  or  as  a  common  belief,  a  con- 
viction of  the  value  of  some  kind  of  herb  or  other  substance  for  the  re- 
lief of  disease. 


CHAPTER  II. 
NUTRITION  IN  RELATION  TO  THERAPEUTICS. 

The  body  may  be  regarded  as  an  apparatus  for  the  manifestation  of 
energy,  and  it  possesses  the  power  of  self-repair  and  self-adjustment. 
Growth,  repair,  and  the  production  of  energ\'  constitute  the  work  of  the 
animal  machine.  All  substances  by  means  of  which  tlie  body  can  main- 
tain its  nutrition  or  either  of  the  processes  named  may  be  called  food  or 
aliments  {(dimentwn,  food,  nutriment,  from  alo,  I  nourish).  Without  a 
due  supply  of  food  nutrition  fails,  and  the  body  can  neither  repair  its 
waste  nor  develop  energy.  The  action  of  the  body  on  food  may  be 
said  to  be  broadly  one  of  oxidation.  On  the  other  hand,  the  result  of 
vegetable  life  is  deoxidation  or  reduction.  The  vegetable  is  an  agent 
for  transmuting-  carbonic  acid,  water,  and  ammonia  into  other  com- 
pounds, and,  further,  light  and  heat  into  chemical  affinity.  The  work 
of  the  animal  is  to  carry  the  vegetable  material  into  higher  structures, 
then  to  destroy  these  compounds  and  change  their  affinities  into  other 
manifestations  of  energy — ultimately  into  heat.  Thus  matter  and  force 
are  alike  ever  moving  in  a  circle.  From  the  mineral  kingdom  the  vege- 
table prepares  compounds  out  of  which  the  animal  can  construct  its 
tissues,  which  having  served  their  purpose  in  the  body  are  oxidized  and 
then  returned  to  the  inorganic  world. 

As  the  production  of  energy  is  mainly,  if  not  entirely  dependent  on 
oxidation,  the  atmospheric  oxygen  might  perhaps  be  included  in  the 
above  wide  definition  of  food,  but  it  is  more  conveniently  considered 
further  on,  and  moreover  such  a  use  of  the  term  does  not  well  accord 
with  the  idea  universally  entertained  of  food,  which  rather  corresponds 
with  the  word  aliment.  Water,  however,  as  the  one  necessary  beverage, 
may  very  well  be  included.  Medicines  do  not  maintain  nutrition  ; 
sometimes  they  interfere  with  it,  and  are  often  said  to  be  substances 
which  act  on  unhealthy  nutrition.  Nevertheless  no  hard  and  fast  line 
need  be  drawn.  Thus  we  have  analeptics  (from  avaXaiifiavu),  I  restore), 
which  restore,  and  sometimes  we  speak  of  a  class  of  nutrients.  Poisons 
may  either  induce  unhealthy  or  prevent  healthy  nutrition.  But  here 
again  there  is  no  sharp  line  Isetween  medicines  and  poisons.  Nature, 
indeed,  does  not  rejoice  in  hard  and  fast  lines,  so  that,  useful  as  we  find 


4  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

them  in  classification,  it  is  well  to  remember  that  this  is  founded  on  arti- 
ficial distinctions,  and  consists  of  groupings  to  aid  the  memory.  There 
is  philosophy  in  the  popular  proverb  in  its  twofold  reading  :  "  What  is 
one  man's  food  is  another  man's  physic,"  or  "  poison,''  as  some  people 
phrase  it. 

Further,  we  may  safely  assert  that  food  is,  in  numerous  cases,  the 
one  medicine  of  prime  value,  as  will  appear  if  we  bestow  a  little  closer 
attention  on  nutrition.  This  process  must  consist  of  both  waste  and  re- 
pair, and  may  therefore  be  looked  at  in  this  twofold  aspect.  It  is  neces- 
sary, first,  for  the  aliment  to  be  presented  to  the  tissues  in  a  condition  in 
which  it  can  be  utilized,  and  then  it  must  become  incorporated  with  or 
assimilated  by  these  tissues,  while  at  the  same  time  the  worn  out  parti- 
cles must  be  removed.  In  lowly  organisms  like  the  amoeba  the  process 
seems  tolerably  simple  :  the  jelly-like  body  simply  flows  around  and  en- 
closes such  food  as  comes  in  its  way;  from  this  is  dissolved  apparently 
the  soluble  portion  which  thus  unites  with  the  jelly-like  mass,  and  this 
in  its  turn  extrudes  the  insoluble  residue  in  a  manner  somewhat  the 
reverse  of  that  by  which  it  surrounded  the  whole.  But  the  higher  we 
rise  in  the  scale  of  animal  life  the  more  complex  becomes  the  process, 
and  the  more  its  several  stages  are  differentiated,  and  so  we  have  to  con- 
sider the  nutrition  of  our  own  bodies  through  the  process  of  digestion, 
absorption,  assimilation,  nutrition  proper,  or  the  renewal  and  waste  of 
tissue,  and  elimination  and  excretion  ;  that  is  to  say,  it  is  essential  for 
our  food  to  undergo  certain  preliminary  changes  before  it  can  be  pre- 
sented to  the  tissues  in  such  a  form  tliat  they  can  act  upon  it  or  be 
acted  upon  by  it. 

Some  substances  may  be  taken  which  are  at  once  rejected  by  the 
digestive  organs  as  useless  or  inconvenient,  but  with  them  others  may 
be  ingested  which  are  of  great  value,  and  are  therefore  at  once  turned  to 
account.  The  nutritious  particles,  then,  are  taken  up,  changed  by  diges- 
tion, absorbed  by  the  alimentary  canal,  poured  into  the  blood,  of  which 
they  thus  become  a  part,  and  are  carried  by  the  circulation  to  every 
portion  of  the  body.  From  the  blood  are  derived  nutrient  fluids  which 
escape  from  the  minutest  vessels  and  continually  bathe  every  particle  of 
every  tissue,  and  while  thus  bathed  it  would  seem  that  each  particle 
yields  up  to  this  bath  whatever  is  useless  or  worn  out,  while  at  the  same 
time  all  such  effete  material  is  replaced  by  the  fresh  contained  in  the 
bath.  A  double  process  is  thus  continually  going  on,  waste  and  repair, 
and  both  are  attended  by  the  liberation  of  energy.  On  the  one  hand 
we  have  wear  and  tear,  the  vital  machine,  as  we  may  sa}',  is  being  con- 
stantly consumed  in  doing  its  own  work:  this  is  a  sort  of  oxidation,  a 
slow  combustion  in  which  the  tissues  are  being  burnt,  and  the  residue 
of  such  combustion,  the  ashes,  so  to  say,  must  be  got  rid  of,  and  accord- 
ingly are  thrown  into  the  surrounding  stream  and  returned  to  the  blood, 


NUTRITION    IN    RELATION    TO    THERAPEUTICS.  5 

which  thus  becomes  a  kind  of  sewer,  and  therefore  in  its  turn  has  to  be 
purified  in  order  to  fulfil  its  double  office.  Provision  is  accordingly 
made  for  removing  these  useless  or  worn-out  products  of  combustion.  On 
the  other  hand,  to  counteract  this  continual  destruction,  or  wear  and 
tear,  we  have  an  equally  constant  process  of  construction,  or  repair,  un- 
interruptedly going  on,  so  that  as  any  used  up  product  is  thrown  into 
the  blood  new  material  is  taken  from  the  same  fluid  to  supply  its  place; 
all  such  new  material,  as  we  have  seen,  must  be  derived  from  the  food.  It 
is  true  we  cannot  observe  the  intimate  molecular  movements  of  nutrition 
as  we  watch  the  reactions  of  chemicals  in  the  laboratory,  but  we  can 
trace  the  aliment  into  the  blood;  this  fluid  finds  its  way  to  every  part; 
we  next  trace  the  disappearance  of  certain  nutrient  ingredients,  and 
then  we  find,  not  them,  indeed,  but  the  products  of  their  combustion 
among  the  constituents  of  the  excretions.  And  these  continual  changes, 
these  marvellous  metamorphoses  are  necessarily  accompanied  with  the 
liberation  of  energy  which  ultimately  manifests  itself  as  heat.  So  long 
as  all  these  changes  continue  we  have  life;  the  arrest  of  them  all  is 
death.  In  health  they  all  go  on  harmoniously,  there  is  a  constant  bal- 
ance, so  to  say,  between  destruction  and  construction.  Let  this  balance 
be  disturbed  and  disease  in  some  form  will  result.  That  some  disturb- 
ance may  occur  within  certain  limits  without  much  injury  is  clear,  espe- 
cially if  only  for  a  short  period,  but  a  prolonged  disturbance,  even  if  in 
so  slight  a  degree  as  to  be  imperceptible,  will  in  time  inevitably  make  it- 
self manifest.  To  compensate  for  slight  disturbance  in  one  direction  we 
have  a  sort  of  reserve:  the  body  can  lay  by  a  store  of  material  and  force 
upon  which  it  may  draw  when  the  aliment  is  insufficient,  and  to  prevent 
the  effects  of  temporary  deprivation.  Hence  nutrition  is  often  compared 
to  banking.  There  is  a  balance,  which  may  vary  from  time  to  time  in 
amount,  but  we  must  pay  in  as  well  as  draw  out,  or  a  time  will  come 
when  our  checks  are  valueless,  and  that  time  will  depend  on  the  amount 
of  the  balance  and  the  demands  made  upon  it. 

So,  as  we  have  said,  the  body  is  a  sort  of  machine,  an  apparatus  for 
the  manifestation  and  employment  of  energy,  every  such  manifestation 
being,  of  course,  attended  by  wear  and  tear,  but  it  possesses  the  power 
of  self-repair,  and  the  material  for  this  purpose  is  obtained  from  the  ali- 
ment. Life,  then,  may  be  said  to  consist  in  a  series  of  perpetual  changes 
in  the  tissues  of  the  body,  which  in  accordance  with  a  physical  law 
necessarily  give  rise  to  the  liberation  of  energy,  and  these  changes  are 
of  two  kinds,  destructive  and  constructive.  If  this  be  so,  the  greater 
or  the  more  rapid  the  changes  the  more  actual  the  life,  and  hence  it  has 
been  plausibly  argued  that  the  more  rapid  the  destruction  of  tissue, 
provided  aliment  be  supplied  for  the  construction  of  new,  the  greater 
will  be  the  degree  of  health.  With  due  limitations  such  a  statement 
may  be  allowed  to  pass,  but  must  not   be  accepted  as  certainly  true  to 


0  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

any  extent  and  in  all  circumstances.  We  may,  indeed,  admit  that  work 
necessarily  being  attended  by  waste,  increase  of  work  should  lead  to 
more  rapid  waste,  as  it  undoubtedly  does,  and  this  again  to  more  rapid 
repair,  more  active  life,  greater  health.  This  is  so  within  certain  limits, 
exercise  is  enjoyable,  the  waste  caused  by  it  is  repaired  quickly,  energy 
is  freely  liberated,  and  bounding  health  with  full  joyous  life  results. 
But  there  is  a  point  when  fatigue  comes  on  and  we  find  that  each  indi- 
vidual machine,  though  all  are  constructed  on  the  same  lines,  is  specially 
adapted  for  its  own  work  and  its  own  rate  of  performing  that  work, 
however  true  it  may  be,  that  as  a  self-repairing,  self-growing,  self-ad- 
justing, and  even  self-improving  machine,  it  may  within  certain  limits 
attain  toward  the  perfection  of  others. 

There  is  one  more  point.  Strange  as  it  may  appear,  when  we  view 
life  from  this  standpoint  it  is  closely  related  to  death.  We  speak  of  the 
stoppage  of  the  machine,  but  the  analogy  fails.  Construction,  repair 
ceases,  but  destruction  goes  on,  or  rather,  after  a  pause  a  new  mode  of 
destruction  begins.  We  have  seen  that  all  the  waste  is  indeed  only  a 
sort  of  combustion  or  oxidation  of  our  tissues.  Well,  after  death,  as 
we  call  it,  these  tissues  decay,  and  what  is  that  but  oxidation  ?  We 
consign  the  no  longer  animate  clay  of  our  beloved  ones  to  the  grave, 
where  it  slowly  moulders  back  to  mother  earth.  The  result  would  be 
the  same  if  we  adopted  the  plan  of  cremation,  and  burnt,  that  is,  rapidly 
oxidized,  their  mortal  remains.  In  either  case  the  products  of  the  oxida- 
tion of  the  body  are  the  same — chiefly  water,  carbonic  acid,  ammonia,  and 
salts;  and  these  are  the  substances  which  during  life  result  from  the  oxida- 
tion of  the  tissues  and  food  which,  as  no  longer  serviceable,  are  excreted. 
So  that  as  in  life  organic  material  is  continually  being  oxidized  and  re- 
turned as  waste  to  the  inorganic  kingdom,  so  in  death  the  same  result 
happens  to  all  the  body  at  once.  The  stages,  indeed,  tln-ough  which  the 
particles  pass  may  vary,  the  rate  of  travelling  may  differ,  the  stopping- 
places  may  not  be  the  same,  but  the  ultimate  goal,  the  end  of  the  jour- 
ney is  the  same  in  death  as  in  life.  "  So  in  the  midst  of  life  we  are  in 
death,"  as  Luther  said,  whose  phrase  has  been  copied  into  our  burial 
service.     Had  Watts  a  poetic  prescience  of  this  when  he  wrote  : 

"  The  moment  when  our  lives  begin 
We  all  begin  to  die  V  " 

To  return.  For  our  present  purpose  we  may  regard  healthy  vital 
action,  life,  if  you  will,  as  a  process  of  continual  destruction  on  the  one 
hand,  counterbalanced  by  compensatory  repair  and  construction  on  the 
other.  But  this  normal  condition  may  vary,  and  then  we  have  disease. 
Alwaj'^s  during  life  destruction  is  going  on  ;  always,  therefore,  its  products 
are  accumulating  and  always  must  be  cast  off.  Now  it  is  easy  to  see 
how  these   actions  may  vary  in  rate  or  be  otherwise  imperfectly  carried 


NUTKITIOJN'    IlSr    RELATION"    TO    THERAPEUTICS.  7 

on,  and  that  such  interruptions  or  imperfections  may  occur  in  any  of 
them. 

The  rate  of  the  destructive  changes  may  be  too  slow  or  too  fast,  and 
in  either  case  mischief  will  ensue.  The  work  may  be  hindered,  or  even 
arrested  at  any  point.  The  removal  of  the  waste  products  may  be  slug- 
gish, and  then  accumulation  may  take  place  within  the  tissues,  at  the 
starting-point,  or  they  may  be  poured  into  the  blood  and  accumulate 
there  from  sluggishness  in  the  organs  of  excretion.  These  products  are 
for  the  most  part  highly  injurious  ;  when  carbonic  acid  is  prevented 
from  being  thrown  out  by  the  lungs  death  soon  occurs,  as  it  also  does, 
though  less  quickly,  when  either  the  skin  or  the  kidneys  cease  to  work. 
Then  again  the  tissues  may  be  imperfectly  oxidized,  in  which  case,  instead 
of  products  precisely  adapted  for  rapid  removal,  other  intermediate  com- 
pounds may  be  thrown  into  the  blood — cinders,  as  it  were,  instead  of  ashes 
— and  these  may  set  up  disease  by  their  directly  poisonous  qualities,  or  by 
the  difficulty  experienced  in  removing  them.  Uric  acid  is  such  an  inter- 
mediate compound,  taking  the  place  of  the  much  more  soluble  urea,  and 
the  relation  of  gouty  affections  to  the  presence  of  that  acid  in  the  blood 
has  been  carefully  investigated.  The  whole  machinery  of  the  body  is  ex- 
tremely delicate,  precisely  adapted  to  accomplish  its  ends,  and  when  any 
part  fails  to  efficiently  perform  its  work,  or  when  a  foreign  substance  ill 
adapted  to  be  utilized  is  present,  we  need  not  wonder  that  such  a  devia- 
tion from  the  conditions  designed  for  its  operations  is  so  injurious  when 
we  see  that  a  grain  of  sand  in  the  oil  with  which  a  watch  is  lubricated 
may  bring  its  movemeTit  to  a  standstill. 

Further,  even  when  elimination  is  equal  to  the  task,  it  is  easy  to  see 
that  destruction  may  vary  in  rapidity.  Such  variation  within  moderate 
limits  may  occur  in  health,  but  if  prolonged  or  excessive  must  give  rise  to 
disease.  The  body  cannot  work  with  tissues  that  need  renewing,  and 
therefore  a  certain  rapidity  of  destruction  and  repair,  or  perhaps  we 
should  rather  say  renewal,  is  essential.  Indeed,  the  more  rapid  the  changes 
within  a  certain  degree  the  more  vigorous  is  the  health,  so  that  slowness 
of  the  process  may  leave  imperfection  in  the  organs.  On  the  other  hand, 
excessive  rapidity  of  destruction  is  also  dangerous.  Tl)e  power  of  repair 
is  limited,  and  if  destruction  goes  on  so  rapidly  that  repair  cannot  keep 
pace  with  it  emaciation  will  take  place.  The  body  will  indeed  feed  on 
itself,  as  we  say,  for  a  time,  use  up  its  stores  which  have  been  laid  by,  but 
when  they  come  to  an  end  it  will  then  consume  itself.  This  is  not  the 
ideal  of  health  ;  rather  it  constitutes  one  form  of  disease.  The  body  wastes, 
though  certain  functions  are  going  on  actively,  and  unless  in  some  way 
the  balance  can  be  redressed,  the  end  of  such  life  is  inevitable. 

Now  let  us  turn  to  the  other  side — construction  or  repair.  This,  like 
its  opposite,  may  vary  in  rate  or  may  be  impeded  or  arrested,  and  that  at 
any  point.     If  the  rate  of  construction  more  than  keeps  pace  with  wear 


8  THERAPEUTICS    OF   THE    KESPIRATORY    PASSAGES. 

and  tear  some  of  the  superfluous  supply  is  rejected,  cast  out  of  the  body 
as  useless,  but  some  of  it  may  be  utilized,  stored  up  in  the  body,  and  thus 
we  may  have  general  increase  of  weight  instead  of  emaciation,  and  this 
in  some  circumstances  may  go  on  to  corpulency  or  obesity.  The  neces- 
sity for  abundant  supplies  to  produce  increase  of  weight  is  well  under- 
stood by  feeders  of  stock.  We  have  seen  that  repair  is  effected  from  ali- 
ment carefully  prepared  within  the  body  itself — elaborated  from  the  food- 
supply.  Now  this  food-supply  may  be  cut  off  from  the  outside,  the  body 
starved,  as  we  say.  So  the  processes  of  elaboration  may  be  impaired  or 
arrested,  or  the  aliment,  when  duly  prepared,  may  be  prevented  from  reach- 
ing the  tissues.  In  either  of  these  cases  the  same  result  ensues — death 
by  starvation.  So,  also,  instead  of  absolute  want  of  aliment  there  may  be 
deficiency,  when  nutrition  will  flag  ;  or  again,  instead  of  insufficiency  of 
nutrient  material  it  may  be  of  inferior  quality,  in  which  case  other  conse- 
quences are  observed — those  spoken  of  as  malnutrition.  The  results  of 
deficiency  of  nutrient  material  resemble  those  of  excessive  waste,  for  wear 
and  tear  is  always  going  on  in  the  living  body,  even  in  the  most  com- 
plete repose  ;  energy  has  to  be  employed  and  its  liberation  is  attended  by 
waste,  oxidation,  consumption  of  material.  Merely  to  keep  up  the  ani- 
mal heat  a  large  consumption  of  fuel  is  necessary — indeed,  most  of  the  food 
of  animals  may  be  regarded  as  such  fuel — so  that  insufficiency  of  this 
fuel  leads  to  loss  of  power  as  well  as  to  decrease  of  weight.  It  is  in  this 
way  that  absolute  deprivation  of  food  soon  brings  about  death. 

Starvation  has  been  carefully  studied  by  Chossat.'  From  his  experi- 
ments it  would  appear  that  death  was  greatly  accelerated  by  a  low  tem- 
perature and  delayed  by  warmth.  Some  of  the  animals,  moreover,  on 
approaching  death  were  revived  by  the  application  of  warmth  and,  being 
then  supplied  with  food,  recovered.  On  the  other  hand,  a  reduction  of 
the  external  air  hastened  death,  just  as  we  know  that  exposure  to  cold 
in  conjunction  with  deprivation  of  food  is  so  much  more  rapidly  fatal. 
In  all  cases  there  was  a  great  loss  of  heat.  At  first  the  fall  was  slight  and 
gradual,  but  later  it  became  rapid,  and  when  it  reached  twenty-nine 
or  thirty  degrees  Fahrenheit  below  normal  death  always  took  place. 
The  variations  of  temperature  were,  however,  not  confined  to  a  regular 
progressive  fall  ;  on  the  contrary,  there  were  frequent  rises  and  falls, 
both  of  them  four  times  greater  than  the  diurnal  variations  of  health, 
presenting  the  phenomena  of  an  extreme  degree  of  hectic.  Besides  the 
temperature,  the  degree  of  emaciation  served  as  an  index  to  the  approach 
of  death,  which  always  took  place  as  soon  as  the  loss  of  weight  amounted 
to  four-tenths  of  the  normal,  from  which,  perhaps,  m'c  may  learn  to  measure 
the  danger  of  progressive  wasting.  It  seems  as  if  the  arrest  of  nutri- 
ment was  at  first  partly  compensated  for  by  slower  waste  ;  for  example, 

'  Chossat  :  Recherclies  experimentales  sur  I'inanition.     Paris,  1843. 


NUTRITIOlSr    IN    RELATION   TO    THERAPEUTICS.  9 

Chossat  found  frequently  that  constipation  occurred,  and  this  we  should 
anticipate,  but  he  reports  that  it  was  afterward  sometimes  replaced  by 
a  peculiar  diarrhoea.  Perhaps,  however,  we  ought  scarcely  to  denomi- 
nate as  diarrhoea  the  evacuation  of  the  grass-green  dry  faeces,  or  even 
the  liquid  saline  matters  he  observed,  especially  as  in  most  cases  of  per- 
sons who  have  been  enclosed  in  mines,  or  otherwise  accidentally  deprived 
of  food,  the  constipation  seems  frequently  to  have  been  nearly  complete. 

So  somnolency  or  stupidity  may  for  a  time  mark  the  mental  state, 
though  later  on  convulsions  or  delirium  may  ensue,  in  either  of  which  life 
may  fail,  or  it  may  terminate  in  gradually  increasing  torpidity.  It  is  in- 
teresting to  note  that  nervous  tissue — the  highest,  as  we  regard  it — seems 
the  last  to  fail,  and  after  death  was  often  found  to  have  preserved  its 
full  weight,  as  if  the  highest  function  of  animal  life  must  be  supplied 
at  whatever  cost  to  the  members. 

We  see,  then,  how  the  consequences  of  starvation  naturally  resemVjle 
those  produced  by  the  interrupted  supply  of  food  brought  about  by  dis- 
ease. Stricture  of  the  oesophagus,  cancer  of  the  stomach,  pressure  of  a 
tumor  on  the  thoracic  duct  alike  interrupt  the  supply  of  aliment  to  the 
tissues,  if  more  gradually  yet  no  less  certainly,  and  the  results  are  the 
same,  though  the  symptoms  may  vaiy.  Tiie  emaciation  would  alone  be 
fatal,  even  if  other  complications  did  )iot  arise  to  hasten  death.  In  other 
cases  where  food  is  insufficient,  where  it  is  not  properly  digested,  where 
assimilation  in  any  of  its  stages  fails,  we  have  progressive  emaciation, 
which  will  be  fatal  unless  the  obstacle  to  the  flow  of  nutriment  from  the 
mouth  to  the  tissues  can  be  removed  in  time.  Again,  the  aliment  may 
be  abundant  but  its  quality  unsuitable,  in  consequence  of  which  the  diges- 
tive organs,  although  active,  may  be  unable  to  extract  what  is  wanted  for 
the  system.  Or  the  fault  may  be  in  some  point  of  the  digestion,  or  elab- 
oration of  the  aliment,  so  that  only  unsuitable  material  is  presented  to 
the  tissues,  which  are  thus  starved,  or  half-starved,  or  ill-fed.  If  all  the 
material  accessible  were  to  be  unfit  for  use  in  a  given  tissue,  and  there- 
fore rejected,  that  tissue  would  be  starved  ;  if  the  supply  were  too  limited 
it  would  be  half-starved  or  deprived  of  nutriment  in  proportion  to  the 
limitation  ;  if  unsuitable  aliment  were  taken  to  make  the  best  of,  then 
the  tissue  would  deteriorate.  Such  products  of  imperfect  elaboration  as 
are  rejected  must  be  carried  away  by  the  blood  in  order  to  be  got  rid  of 
by  excretion.  If  they  were  to  be  retained  in  the  blood  its  quality  would 
be  deteriorated  ;  and,  indeed,  they  might  act  as  powerful  poisons,  as  we 
know  that  many  used-up  products  do  ;  or  again,  they  might  set  up  disease 
in  the  organs  on  which  was  thrown  the  work  of  excreting  them. 

What  we  have  said  of  nutrition  has  been  for  the  most  part  with  ref- 
erence to  the  body  as  a  whole,  but  very  similar  statements  might  be  made 
as  to  each  of  its  parts,  and  we  may  study  the  process  as  a  local  one  with 
equal  profit.     Interrupt  the  blood-supply  of  a  part  and  it  perishes  ;  pre- 


10  TnERAPEUTICS    OF    THE   RESPIRATORY   PASSAGES. 

vent  the  blood  from  leaving-  it  and  the  effects  are  also  disastrous  ;  changes 
in  the  rate  of  circulation  in  parts  are  common  enough  in  disease.  But 
it  is  not  necessary  here  to  dwell  further  on  interferences  with  local  nu- 
trition. 

With  regard  to  the  function  of  aliment,  though  we  have  hitherto 
chiefly  kept  in  view  the  maintenance  of  tissues  and  the  repair  of  their 
wear  and  tear,  we  must  not  forget  its  work  as  a  liberator  of  energy. 
This  is  manifested  as  movement,  either  muscular  or  molecular,  as  chem- 
ical or  electrical  action,  and  ultimately  as  heat.  Indeed,  the  larger  part  of 
our  food  is  required  for  keeping  up  the  animal  heat  ;  this  explains  why 
a  fall  of  the  temperature  of  the  body  so  constantly  attends  starvation  ; 
why  when  function  is  active  there  is  increase  of  heat,  and  vice  versa. 

Here  it  may  be  asked,  Must,  then,  all  food  be  converted  into  tissue 
before  it  can  generate  action  ;  may  not  energj'  also  arise  from  the  trans- 
mutations of  nutrient  material  dissolved  in  the  blood,  which  may  itself 
be  regarded  in  many  respects  as  a  fluid  tissue  ?  This  question  has  given 
rise  to  much  debate  among  chemists  and  physiologists,  some  holding  one 
view  and  some  the  other.  Liebig  maintained  that  muscular  force  is 
alwaj^s  obtained  from  the  nitrogenous  constituents  of  muscle.  At  one 
time,  he  regarded  the  action  as  a  simple  combustion,  but  later  he  modi- 
fied his  view,  supposing  that  the  oxygen  might  not  necessarily  cause 
though  it  must  take  part  in  the  action,  and  that  no  oxidation  of  nitro- 
genous material  could  occur  until  it  had  become  organized  tissue,  so  that 
all  the  energy  of  the  animal  machine  must  be  derived  from  its  own  com- 
bustion. Others,  however,  hold  that  energy  is  liberated  by  the  combus- 
tion of  alimentary  material,  generally  non-nitrogenous,  in  the  blood,  and 
it  has  been  shown  that  for  a  short  period  great  labor  may  be  undergone 
on  a  non-nitrogenous  diet,  and  that  while  there  is  always  a  relation  be- 
tween the  quantity  of  nitrogen  ingested  and  excreted,  nevertheless 
this  last  amount  is  not  so  related  to  the  work  of  the  body.  Still,  no 
manifestation  of  energy  takes  place  without  the  participation  in  some 
manner  of  nitrogenous  structures,  which,  if  they  do  not  carry  on,  at  any 
rate  appear  to  initiate  the  action.  In  this  action  the  tissue  is  worn  out. 
It  has  been  shown  by  Pettenkofer  and  Voit  that  the  tissue-changes  de- 
termine the  absorption  of  oxygen,  its  conversion  into  ozone,  and  its  use 
in  combustion  ;  so  that  its  appropriation  and  use  appears  to  be  entirely 
dependent  on  the  action  of  these  tissues. 

Hitherto  nothing  has  been  said  about  the  control  exercised  over  nu- 
trition and  other  processes  by  the  nervous  system,  because  the  points  to 
be  principally  enforced  are  presented  more  simply  by  the  omission  ;  and 
our  readers  as  medical  men  will  be  able  to  supplement  the  sketch  given. 
Whether  great  believers  or  not  in  the  functions  ascribed  to  trophic 
nerves,  they  will  know  well  enough  that  every  action  of  the  organism  is 
dominated  by  the  nervous  system  ;  and  we  may  defer  further  considera- 


jSrUTIUTIOlS'    IN    KELATION    TO    THERAPEUTICS.  11 

tioii  of  its  influence  over  nutrition  in  its  several  stages  with  the  remark 
that  such  influence  may  also  be  varied  somewhat  in  health,  much  more 
in  disease,  and  that  the  variations  may  appear  as  increase,  decrease,  or 
perversion  of  the  normal  action. 

Besides,  we  cannot  undertake  to  give  a  complete  dissertation  on  the 
physiology  of  nutrition  ;  but  only  to  set  forth  what  may  seem  necessary 
for  the  purpose  in  hand.  Some  readers,  indeed,  may  already  be  impa- 
tiently asking.  What  has  all  this  to  do  with  therapeutics  and  more  par- 
ticularly the  therapeutics  of  respiratory  diseases  ?  To  them  I  reply, 
Much  every  way.  In  the  first  place,  as  already  stated,  food  is  pliysic, 
and  what  has  been  said  as  to  nutrition  goes  far  to  show  how  and  why. 
The  balance  between  destructive  and  constructive  tissue-chano^es  beinff 
disturbed,  it  may  often  be  restored  by  the  proper  use  of  aliments  or  nu- 
trients, or,  as  we  call  them  in  such  case,  analej)tics.  So,  too,  it  may  happen 
that  in  opposite  conditions  the  restriction  of  nutriment  may  suffice.  In 
a  third  case,  the  impaired  or  perverted  nutrition  may  be  remedied  by 
regulation  of  tlie  diet.  In  all  such  cases  alimentary  substances  constitute 
our  materia  medica  and  the  principles  of  dietetics  our  therapeutics.  It 
may  be  added  that  in  few  diseases  are  questions  relating  to  nutrition  of 
greater  importance  than  in  those  that  affect  the  respiratory  organs. 

In  the  next  place,  articles  which  have  little  or  no  claim  to  be  regarded 
as  food,  but  which  are  commonly  spoken  of  as  medicines,  are  taken  into 
the  system  by  the  same  channels  as  food,  and  follow  the  same  route  to 
the  inner  arcana  of  the  economy,  and  having  produced  their  influence 
there  are  again  carried  out  of  the  body  by  the  same  way,  and  are  there- 
fore liable  to  be  acted  on  by  the  same  influences  throughout  that  journey. 
The  gastric  juice,  the  liver,  the  pancreatic  and  intestinal  juices  may  all 
modify  our  medicines  or  be  modified  by  them.  So,  too,  the  blood  may 
act  upon  them  or  be  acted  upon  by  them  before  they  can  reach  the 
organs  or  tissues  on  which  their  influences  are  exerted.  So,  again,  the 
several  parts  with  which  they  come  into  contact — stomach,  alimentary 
canal,  etc. — before  entering  the  system  may  be  influenced  by  their  local 
action.  It  is  true  that  some  of  them  are  at  once  taken  into  the  blood 
without  suffering  any  change  in  the  digestive  organs  ;  others  we  delib- 
erately introduce  into  the  cellular  tissue,  and  so  avoid  the  route  by  the 
alimentary  canal  ;  others,  again,  we  introduce  into  the  lungs  by  inhala- 
tion, obtaining  in  this  way,  in  some  cases,  invaluable  local  action,  and  in 
others  exceedingly  rapid  effects  on  the  whole  system  in  consequence  of 
their  speedy  absorption  ;  others,  again,  we  direct  immediately  into  the 
blood-stream  through  the  veins.  But  the  statement  remains,  that,  what- 
ever the  channel,  it  may  or  may  not  be  locally  affected  by  the  medicine. 
In  the  former  case  the  action  may  be  reflected,  so  to  say,  and  give  rise  to 
an  indirect  effect  upon  the  system.  From  the  air-passages,  when  ab- 
sorbed, medicines  are  taken  up  unchanged  by  the  blood,  but  in  the  ali- 


12  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

mentary  canal  tliey  are  liable  to  be  acted  upon  by  the  digestive  fluids. 
It  is  clear  enough  that  the  gastric  juice  may  be  reinforced  by  acids  or 
neutralized  by  alkalies,  but  other  changes  are  also  important,  though  too 
generally  neglected. 

Passing  to  the  next  stage,  the  effects  of  our  remedies  may  be  princi- 
pally manifested  in  the  blood,  which  may  be  impoverished  or  enriched  or 
otherwise  changed  by  their  action,  as  in  the  case  of  haematics  (ai/za, 
blood),  hjematinics  on  the  one  hand  or  spansemics  (o-Travos,  poor,  and  al/xa, 
blood)  on  the  other.  Having  thus  reached  the  circulation  the  medi- 
cines, either  in  their  original  form  or  changed  by  the  blood,  are  carried 
by  it  to  the  various  tissues,  and  may  produce  their  principal  effects  on 
them,  as  for  example  neurotics  (from  vevpov  a  nerve),  which  act  upon  the 
nervous  system.  Or,  again,  they  may  influence  the  function  of  organs, 
such  as  the  heart,  on  which  cardiac  stimulants  or  cardiac  depressants  pro- 
duce their  effects,  and  of  course  through  that  the  whole  vascular  system 
may  in  some  cases  be  affected.  Still  later,  having  done  certain  work  or 
liberated  energy — either  hastening,  retarding,  or  otherwise  changing  the 
nutrition  of  the  body  or  of  some  part  of  it,  or  of  special  tissues,  or  per- 
haps liaving  influenced  some  special  organ — such  medicines,  or  "  poisons," 
may  be  either  deposited  in  the  tissues  or  the  viscera,  or,  as  is  much  more 
frequently  the  case,  may  be  raj^idly  eliminated.  In  this  last  stage  of 
their  journey  in  and  out  of  the  system,  during  the  very  process  of  excre- 
tion they  may  affect  considerably  any  parts  through  which  they  pass — 
again  hastening,  retarding,  or  interfering  with  the  work  of  the  excretory 
organs,  most  frequently  the  first,  as  we  see  in  the  extensive  group  of 
evacuants. 

The  medicines  we  thus  administer  are  very  various  in  their  nature 
and  properties.  Some  are  simple  salts  on  which  the  body  often  appears 
to  have  little  influence  and  which  are  quickly  restored  to  the  mineral 
kingdom.  Others  exercise  much  greater  influence,  often  chiefly  or  en- 
tirely of  a  chemical  kind,  and  after  some  changes  are  excreted  in  such 
compounds  as  might  be  anticipated.  Others  linger  still  longer  in  the 
system — if  they  do  not  become  tissues,  at  least  form  some  close  union 
with  them,  and  consequently  have  some  claim  to  be  regarded  as  supple- 
mentary food  or  a  partially  necessary  aliment.  Iron,  for  instance,  must 
be  supplied  to  the  blood,  which  requires  it  for  the  production  of  haemo- 
globin. The  amount  required  is  usually  obtained  from  the  food,  but  some- 
times— perhaps  from  excessive  waste,  perhaps  from  deficient  supply, 
perhaps  in  consequence  of  loss  of  blood  or  of  some  disturbance  of  the  bal- 
ance not  so  easily  traced — it  is  not  present  in  sufficient  quantity,  and  then 
the  blood  thus  impoverished,  so  far  as  concerns  one  of  its  ingredients, 
fails  to  perform  its  work  perfectly,  and  anaemia  (from  a,  privative,  al/xa, 
blood)  is  said  to  be  present.  This  may  often  be  removed  by  a  suit- 
able  diet,  because  the  iron  which  the   system  lacks  is   present  in   appro- 


NUTRITION    IN    RELATION    TO    THERAPEUTICS.  13 

priate  food.  So  it  may  by  fresh  air,  exercise,  and  other  influences  which 
stimulate  oxidation,  and  in  other  cases  by  chalybeates  (from  Chalybs, 
XOi^v^,  a  name  for  the  metal  derived  from  the  Chalybes,  a  people  in  Pon- 
tus,  who  used  to  work  it),  because  they  put  within  the  system  the  miss- 
ing metal,  which  may  thus  far  be  considered  an  aliment.  And  so  with 
regard  to  some  other  medicines.  But  further,  not  only  may  nutrition  be 
modified,  but  all  organs,  all  tissues,  all  fluids,  perhaps  all  modes  of  energy 
developed  within  the  body,  may  be  influenced  in  some  way  by  agents  in- 
troduced or  brought  to  bear  upon  it,  and  which  therefore  constitute  our 
materia  medica. 


CHAPTER    III. 

EESPIRATION. 

We  have  seen  how  nutrition  consists  of  a  perpetual  balance  between 
destruction  and  construction.  Tissue  waste  is  incessantly  going  on,  and 
new  material  is  as  constantly  brought  to  take  the  place  of  the  old,  while 
the  debris  must  as  regularly  be  removed.  The  process  is  analogous  to  that 
of  respiration.  We  inspire  fresh  air,  we  expire  carbonic  acid  and  some 
other  material  ;  and  this  work,  too,  may  be  impeded  or  may  be  arrested, 
and  that,  also,  in  any  part  of  its  progress.  The  oxyg-en  passes  into  the 
lungs,  is  taken  up  by  the  blood,  is  carried  by  the  circulation  to  the  tissues, 
where  its  work  is  done,  is  then  returned  as  carbonic  acid  in  the  venous 
stream,  brought  back  to  the  lung  and  expired  into  the  atmosphere.  If 
we  cut  off  the  supply  of  fresh  air  asphyxia  is  speedy,  if  we  limit  its 
quantity  the  process  is  slower,  and  it  matters  not  whether  the  access  of 
air  be  prevented  by  something  external  or  within  tlie  body.  Closure  of 
the  larynx  or  trachea  by  the  intrusion  of  a  foreign  body  is  as  fatal  as 
hanging  or  enclosing  an  animal  in  a  vessel  containing  no  oxygen.  Ob- 
struction of  the  bronchi  or  pulmonary  cells  by  the  products  of  disease 
may  also  asphyxiate.  So,  also,  the  atmosphere  may  be  so  contaminated 
as  to  be  unfit  for  the  purposes  of  respiration.  Again,  to  prevent  the  ex- 
halation of  the  carbonic  acid  is  just  as  fatal  as  to  arrest  the  entrance  of  air, 
and  such  prevention  may  occur  at  any  part  of  the  journey.  How  often 
in  respiratory  diseases  is  the  patient  poisoned  by  the  carbonic  acid  which 
he  is  unable  to  get  rid  of,  asphyxiated  by  the  product  of  his  own  function 
which  the  lungs  fail  to  excrete.  So,  too,  the  rate  of  respiration,  which 
varies  somewhat  in  health,  may  in  disease  present  great  modifications. 

But  we  must  examine  the  function  of  respiration  a  little  more  in 
detail.  The  first  point  is,  that  oxygen,  being  continually  used  in  the 
tissues,  must  constantly  be  brought  to  them.  This  is  accomplished  by 
the  circulation,  which  also  takes  away  the  carbonic  acid  and  other  refuse. 
The  oxygen  passes  into  the  blood  mainly  by  diffusion,  by  which  process 
also  carbonic  acid  passes  from  the  tissues  to  the  blood  and  from  that  to 
the  air.  Although  a  portion  of  the  interchange  between  the  body  and 
the  atmosphere  takes  place  elsewhere  the  lungs  are  the  chief  organs  of 
this  process.     Through  the  alternate  inspiration  and  expiration  a  regular 


KESPIKATION.  15 

ebb  and  flow  of  tidal  air  is  established  and  the  stationary  air  is  renewed 
by  diffusion  from  this.  Tlie  ordinary  amount  of  air  in  the  lungs  of  an 
adult  after  a  full  inspiration  averages  330  cubic  inches.  Of  this  the 
tidal  air,  or  that  which  is  inspired  and  expired  in  every  respiration,  is 
estimated  at  only  30  cubic  inches  ;  the  complemental  air,  or  that  which 
can  be  inspired  after  an  ordinary  inspiration,  110  cubic  inches  ;  the  re- 
serve, or  that  w^hich  can  be  expired  after  an  ordinary  expiration,  and  the 
residual,  or  that  which  remains  after  the  fullest  possible  expiration,  are 
each  estimated  at  100  cubic  inches.  What  we  call  the  vital  capacity  is 
the  sum  of  the  tidal,  complemental,  and  reserve,  that  is  to  say,  the  total 
amount  of  air  which  can  be  given  out  by  expiration  after  the  fullest  forci- 
ble inspiration.  This  in  a  man  5  feet  8  inches  high,  averages  230  cubic 
inches,  and  this  is  what  we  measure  by  the  spirometer.  Dr.  John  Hutchin- 
son showed  ("  Med.  Chir.  Trans.,"  1858)  that  the  vital  capacity  differs 
with  the  height,  posture,  weight,  and  age  of  the  patient,  but  is  much  more 
modified  by  disease.  Every  additional  inch  of  stature  from  five  to  six  feet 
enables  the  patient  to  breathe  eight  cubic  inches  additional.  As  the  move- 
ments of  the  thoracic  walls  are  more  free  in  the  erect  posture  the  vital 
capacity  should  be  taken  in  that  position.  It  increases  from  fifteen  to 
thirty-five  years  of  age  and  then  diminishes  to  sixty-five.  Usually  it  in- 
creases with  the  weight  of  the  person.  There  is  a  g-reat  diminution  in 
almost  all  thoracic  diseases,  not  only  in  tumors,  abscesses,  and  effusions, 
which  may  be  said  to  displace  the  air,  but  even  in  the  early  stage  of 
phthisis,  in  which  the  respiration  is  evidently  weakened.  Instead  of  es- 
timating the  air  contained  in  the  chest  we  may  measure  the  movements 
of  its  walls.  Sibson's  chest-measurer  registers  the  changes  in  tlie  hori- 
zontal posture  in  the  antero-posterior  diameter  of  the  chest  ;  Ransome's 
stethometer  measures  the  movements  of  the  walls  in  several  diameters  ; 
Riegel's,  Marey's,  and  Burdon-Sanderson's  ("Hbk.  Phys.,"  p.  291)  fur- 
nish graphic  records. 

In  ordinary  inspiration  the  two  principal  means  of  enlarging  the  chest 
are  the  descent  of  the  diaphragm  and  the  elevation  of  the  ribs  ;  expi- 
ration is  mainly  accomplished  by  elastic  reaction.  In  labored  inspiration 
all  the  muscles  which  can  elevate  the  ribs,  or  which  can  contribute  to  the 
support  of  those  which  can,  are  brought  into  play  ;  and  in  labored  expira- 
tion all  those  which  can  depress  the  ribs  or  press  on  the  abdominal  vis- 
cera or  afford  a  fixed  support  to  those  which  act  in  this  way,  are  thrown 
into  powerful  action.  The  associated  respiratory  movements,  both  facial 
and  glottic,  may  be  observed  even  in  tranquil  respiration,  but  are  greatly 
exaggerated  in  dyspnoea. 

In  respiration  the  air  loses  four  or  five  per  cent,  of  oxygen  but  gains 
four  per  cent,  of  carbonic  acid  and  becomes  saturated  with  moisture. 
Haemoglobin  is  the  purveyor  of  oxygen.  This  body,  without  any  further 
change,  takes  up  in  the  lungs  oxygen,  holding  it  loosely  in  combination 


16  THERAPEUTICS    OF   THE    EESPIRATORY    PASSAGES. 

and  may  then  be  called  oxyhsemoglobin,  which  is  carried  by  the  circulation 
to  the  tissues.  These  rob  it  of  its  surplus  oxygen,  and  so  it  becomes 
a^aiu  reduced  to  haemoglobin  and  must  go  back  to  the  lungs  to  obtain 
a  further  supply  of  oxygen.  The  amount  of  change  varies  in  different 
tissues,  and,  indeed,  in  the  same  tissues  at  different  times,  e.g.,  whether 
they  are  at  work  or  at  rest.  It  will  be  observed  that  we  treat  oxidation 
as  taking  place  in  the  tissues,  though  it  has  sometimes  been  thought  that 
part  at  least  of  the  process  was  carried  on  in  the  blood,  as  if  certain  oxi- 
dizable  substances  were  taken  up  into  the  blood  and  there  oxidized.  If 
such  were  the  case,  the  chief  oxidation  would  be  in  the  blood,  but  all 
available  evidence  points  to  the  conclusion  that  the  locality  of  oxidation 
is  the  tissues.  It  is  true  that  certain  reducible  substances  may  be 
detected  in  the  blood,  but  only  in  too  small  quantity  to  be  of  any  ac- 
count ;  moreover,  shed  blood  has  no  action  on  various  substances  which 
are  unquestionably  oxidized  in  the  living  body.  Grape-sugar,  for  ex- 
ample, when  added  to  blood  is  not  oxidized,  even  though  the  mixture 
be  kept  at  the  temperature  of  the  body  ;  and  further,  a  slight  excess  of 
sugar  in  the  system  instead  of  being  oxidized,  is  discharged  unchanged. 
So  too,  pyrogallic  acid  passes  through  the  system  without  change, 
although  it  is  a  very  oxidizable  body.  Citric  and  other  acids  are  scarcely 
at  all  oxidized  in  the  body,  and  even  when  given  in  combination  with 
alkaline  bases  are  only  partially  oxidized.  We  conclude,  then,  that  it  is 
in  the  tissues  that  the  change  takes  place,  and  this  explains  why  certain 
diffusible  substances  which  the  tissues  refuse  to  take  up  are  removed  by 
the  secreting  organs,  whereas  it  would  seem  that  they  must  be  oxidized  if 
that  process  took  place  to  any  considerable  extent  in  the  blood. 

The  blood,  then,  by  virtue  of  its  corpuscles,  these  by  virtue  of  their 
haemoglobin,  takes  up  oxygen  in  the  lungs,  becomes,  as  we  say,  arterial, 
and  goes  as  such  to  the  tissues  where  the  oxygen-tension  is  low.  They 
therefore  receive  oxygen  from  the  blood  and  store  it  up  in  some  stable 
combination,  leaving  the  haemoglobin  reduced,  that  is,  more  or  less  of  it, 
according  to  the  activity  of  the  tissue.  As  carbonic  acid  is  continually 
produced  in  the  tissues,  its  tension  is  always  higher  there  than  in  the 
blood,  and  therefore  it  passes  into  the  stream.  Accordingly,  the  venous 
blood  has  not  only  its  haemoglobin  reduced  but  its  carbonic  acid  tension 
increased,  so  that  on  reaching  the  lungs  the  gas  streams  through  the  vas- 
cular and  alveolar  walls  till  the  tension  without  is  equal  to  that  within. 
Then  the  stationary  air,  having  lost  oxygen  and  gained  carbonic  acid,  has 
a  lower  oxygen  tension  and  a  higher  carbonic  acid  tension  than  the  tidal  air, 
in  consequence  of  which  rapid  diffusion  between  these  two  takes  place, 
so  that  at  last  the  air  issues  from  the  body  poor  in  oxygen  but  rich  in 
carbonic  acid.  It  is  calculated  that  it  requires  from  six  to  ten  respirations 
to  completely  renew  the  air  in  the  lungs. 

Variations  in  the  atmospheric  pressure  necessarily  produce  important 


RESPIRATIOlSr.  17 

effects.  Living  at  the  bottom  of  an  atmospheric  ocean  some  fifty  miles 
deep,  the  normal  pressure  of  nearly  fifteen  pounds  to  the  square  inch 
gives  us  thirty  thousand  to  forty  thousand  pounds  total  pressure  on  the 
surface,  according  to  the  size  of  the  person.  This  is  at  the  sea-level.  On 
lofty  mountains  it  is  considerably  less  and  it  diminishes  rapidly  in  a  bal- 
loon ascent.  To  gradual  changes  we  can  accommodate  ourselves,  but  in 
mountaineering  they  are  perceptible  and,  of  course,  aggravated  by  the 
necessary  exertion.  In  ballooning  the  ascent  is  so  sudden  that  very  un- 
pleasant symptoms  are  often  produced  from  the  diminution  of  the  press- 
ure. Thus  the  congestion  of  the  capillaries  of  the  skin  and  free  mucous 
surface  leads  to  sweating,  mucous  discharges,  and  sometimes  hemor- 
rhages. The  capillary  resistance  being  lessened,  the  heart  beats  more  fre- 
quently, and  some  dyspnoea  is  felt,  the  respirations  are  deeper  but  some- 
what irregular.  Muscular  weakness  and  exhaustion  are  also  complained 
of,  with  either  dyspnoea  or  oppression  and  constriction  of  the  chest. 
Perhaps  these  symptoms  are  due  to  insufficient  oxygen  and  imperfect 
elimination  of  carbonic  acid.  Vomiting  is  sometimes  produced,  which 
may,  perhaps,  be  attributed  to  stimulation  of  the  vagal  centres  in  conse- 
quence of  deficient  oxygen.  As  the  blood  is  drawn  to  the  surface  the 
brain  has  a  less  supply  and  this  often  leads  to  faintness.  Diminished 
secretion  of  urine  may  be  explained  in  the  same  manner. 

The  effects  of  increased  pressure  may  be  seen  in  descending  below  the 
sea  level,  as  in  mines  and  in  works  carried  on  in  an  atmosphere  of  com- 
pressed air,  as  in  the  diving-bells  or  caissons  for  laying  the  foundations  of 
bridges.  In  this  case  the  skin  becomes  pale,  perspiration  is  diminished, 
and  the  respirations  are  from  two  to  four  less  in  the  minute  ;  inspiration 
is  easier,  but  expiration  is  prolonged,  and  there  is  a  distinct  pause  be- 
tween the  movements  ;  the  vital  capacity  increases,  so  does  the  secre- 
tion of  the  kidne3's  ;  muscular  efforts  are  made  with  more  energy  and 
activity  ;  the  heart,  meeting  with  more  resistance  from  the  contraction 
of  the  cutaneous  capillaries,  beats  slower,  and  the  pulse-curve  is  lower ; 
there  is  a  subjective  sensation  of  warmth.  Persons  should  not  return 
suddenly  to  the  normal  pressure  or  the  blood  will  be  drawn  to  the  surface, 
as  if  the  body  had  been  placed  in  a  vacuum,  and  there  will  be  hemorrhage 
from  the  nose,  mouth,  ears,  etc.,  while  the  sudden  removal  of  blood  from 
the  centres  may  bring  on  paralysis. 

The  oxygenation  of  the  blood  may  be  impeded  or  totally  arrested  by 
various  circumstances,  as  bv  want  of  oxygen  when  an  animal  is  placed  in 
confined  air,  in  a  vacuum,  in  an  atmosphere  of  nitrogen,  or  under  water  ; 
in  the  foetus  from  the  separation  of  the  placenta  or  pressure  on  the  cord  ; 
by  interruption  of  the  cutaneous  respiration  by  varnishing  the  skin.  We 
may  also  have  closure  of  the  air-passages,  either  partial  or  complete,  tem- 
porary or  permanent,  as  in  strangulation,  spasm  of  the  glottis,  pressure 
from  without  by  tumors,  accumulation  within,  as  of  mucus  in  the  bronchi 


18  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

or  even  hemorrhage.  Then,  again,  we  may  have  collapse  of  the  lung  from 
the  entrance  of  air  or  liquid  into  the  pleura,  as  in  pneumo-thorax  and 
pleuritic  exudation.  So,  too,  partial  destruction  of  the  lung,  as  in  phthisis, 
or  cessation  of  respiratory  movement,  or  embolism  of  the  pulmonary  ar- 
tery will  bring  about  the  same  condition. 

In  a  chamber  of  rarefied  air  an  animal  will  die  before  the  oxygen  is 
exhausted,  a  result  attributed  by  Hoppe-Seyler  to  the  evolution  of  gas  in 
the  blood,  which  disturbs  the  circulation.  In  compressed  air,  the  death 
is  believed  by  Paul  Bert  to  be  due  to  the  elimination  of  carbonic  acid  be- 
ing hindered. 

In  the  complete  absence  of  oxygen,  or  when  the  gas  is  entirely  pre- 
vented from  reaching  the  alveoli,  death  speedily  ensues.  As  the  oxygen 
diminishes  the  carbonic  acid  increases,  the  accessory  muscles  of  respira- 
tion are  then  called  into  action  and  the  movements  are  deeper  but  slower. 
This  degree  of  dyspnoea  is  a  compensatory  act,  bringing  in  more  oxygen 
when  it  can  be  obtained  and  ceasing  on  its  arrival.  A  further  want  of 
oxygen  sets  up  clonic  convulsions — that  is,  spasms  of  all  the  muscles  of  the 
body.  These  seem  to  be  due  to  stagnation  of  blood  in  the  brain — venous 
blood,  poor  in  oxygen,  rich  in  carbonic  acid — for  they  occur  when  arterial 
blood  is  prevented  from  going  to  the  brain,  as  by  ligature  of  the  carotids 
and  vertebrals,  as  well  as  when  venous  blood  is  prevented  from  returning, 
and  also  after  hemorrhage.  A  further  want  of  oxygen  causes  the  centres 
to  lose  their  irritability  and  asphyxia  results. 

When  there  is  a  long-continued  want  of  oxygen,  but  only  of  a  mod- 
erate degree,  there  is  an  adjustment  between  the  requirements  and  the 
supply,  the  functions  associated  with  oxidation  diminish,  the  tempera- 
ture is  lower,  the  muscles  are  flaccid,  the  respiration  is  more  rapid,  the 
smaller  arteries  and  capillaries  relax,  and  the  darker  color  of  the  imper- 
fectly arterialized  blood  is  seen  through  the  lips,  mucous  membranes,  and 
portions  of  the  skin.      This  is  cyanosis. 

The  supplementary  respiration  performed  by  the  skin  resembles  in 
character  that  carried  on  in  the  lungs.  In  both  we  see  a  rich  plexus  of 
capillaries  separated  from  the  atmosphere  by  epithelial  structure,  but  in 
the  skin  the  latter  is  many  times  thicker  than  in  the  lungs,  as  we  find  the 
carbonic  acid  excreted  through  the  cutaneous  surface  in  much  smaller 
amount  than  that  removed  by  the  pulmonary  surface — the  proportion  be- 
ing as  one  to  thirty-eight — but  the  water  removed  by  the  skin  is  about 
two  pounds  per  day,  double  the  amount  which  escapes  in  the  form  of 
vapor  from  the  lungs. 

As  respiration  involves  the  continual  co-ordinated  acts  of  many  mus- 
cles the  nervous  control  of  these  movements  demands  attention.  The 
harmony  of  their  action  is  complete,  and  that  in  labored  as  well  as  in 
gentle  breathing.  Observation  and  experiment  teach  us  that  the  co-ordi- 
nating impulses  proceed  from  the  medulla,  and  from  a  small  point  in  the 


RESPIRATION.  19 

medulla  which  we  call  the  respiratory  centre.  The  respiration  goes  on 
after  the  removal  of  the  brain  above  the  medulla  and  on  section  of  the 
cord  just  below  it,  though  the  thoracic  movements  cease  ;  the  centre  con- 
tinues in  action,  for  the  facial  and  glottic  movements  continue,  but  these 
cease  when  the  recurrent  laryngeal  nerves  are  divided.  When  that 
small  portion  of  the  medulla  which  Flourens  called  the  nmud  vital  is 
destroyed,  breathing  ceases  forever,  though  every  other  part  of  the  ner- 
vous system  be  uninjured,  and  as  the  inhibitory  vagus  centre  is  gen- 
erally stimulated  at  the  same  time,  the  heart's  beat  is  arrested  and  the 
animal  killed.  This  noeud  vital,  then,  we  call  the  respiratory  centre,  and 
its  rhythmic  action  is  not  merely  reflex  but  automatic.  Respiratory  im- 
pulses start  de  novo  from  this  centre,  though  their  character  may  be 
altered  by  afferent  impulses  arriving  at  the  moment  when  they  are  gen- 
erated. As  the  centre  communicates  with  the  lungs  by  the  vagi  no 
doubt  afferent  impulses  started  by  any  stimulus  to  their  peripheral  end- 
ings continually  ascend  and  produce  modifications,  which  changes  have 
reference  chiefly  to  the  distribution  in  time  of  the  efferent  impulses. 
When  the  vagi  are  divided  respiration  becomes  much  slower,  the  pauses 
between  inspiration  and  expiration  being  lengthened,  but  each  respira- 
tion is  fuller  and  deeper,  so  that  the  oxygen  consumed  and  the  carbonic 
acid  lost  in  a  given  time  are  about  the  same,  the  loss  in  rate  being  made 
up  in  extent.  Stimulation  of  the  divided  vagi  by  a  gentle  interrupted 
current  quickens  the  respiration,  and  by  careful  management  the  natu- 
ral rhythm  may  be  restored,  but  a  too  powerful  current  accelerates  the 
breathing  too  much,  and  may  throw  the  diaphragm  into  a  tetanic  condi- 
tion and  bring  about  a  standstill  of  respiration  in  the  inspiratory  phase. 
The  respiration  is  also  rendered  slower  by  stimulating  the  central  end  of 
the  superior  laryngeal  branch  of  the  vagus,  and  that  whether  the  trunk 
of  the  vagus  (below  the  origin  of  that  branch)  be  divided  or  not,  and 
this  stimulus  may  bring  about  a  standstill  in  the  phase  of  rest,  that  is  in 
the  normal  expiratory  phase.  We  conclude,  therefore,  that  the  superior 
laryngeal  nerve  contains  fibres  the  stimulation  of  which  inhibits  the 
respiratory  centre,  while  the  main  trunk  of  the  vagus  contains  fibres  the 
stimulation  of  which  augments  the  action  of  that  centre  ;  but  as  in  some 
cases  there  is  a  retardation,  we  conclude  further  that  the  main  trunk 
contains  some  inhibitory  fibres,  though  the  accelerating  ones  are  much 
more  numerous,  and  these  accelerating  fibres  appear  from  the  result  of 
dividing  them  to  be  always  at  work.  The  rhythmic  impulses  of  the  res- 
piratory centre  seem  to  be  excited  by  the  blood,  or  rat.her  its  condition  : 
the  more  venous  its  character,  the  greater  is  the  stimulus.  The  breath- 
ing becomes  quicker  and  deeper  whenever  the  arterialization  is  defect- 
ive. Greater  activity  in  the  tissues — loading  up  carbonic  acid  and 
using  oxygen,  as  in  muscular  exertion — makes  the  respiration  more 
active,  as  does  any  hindrance  to  air  entering  the  lungs.     In  obstruction 


20  THERAPEUTICS    OF    THE    RESPIRATORY   PASSAGES. 

to  respiration,  as  the  blood  becomes  more  venous  the  nervous  discharges 
of  the  centre  are  more  vehement,  and,  so  to  say,  overflow  and  set  other 
muscles  in  action,  and  this  may  go  on  until  the  centre  is  exhausted. 
Instead  of  being  too  venous,  the  blood  may  be  made  less  venous — as  by 
breathing  oxygen,  or  by  forcible  voluntary  breathing,  or  by  artificial  res- 
piration vigorously  carried  on.  Then,  the  blood  having  obtained  all  the 
oxygen  it  needs,  the  centre  is  no  longer  stimulated  by  a  want  of  it,  and 
respiration  ceases  until  tissue-changes  render  the  blood  again  venous. 
In  such  case  the  centre  is  at  rest,  and  we  have  what  many  physiologists 
call  "  apnoea,"  following  in  this  Rosenthal,  who  thus  employed  the  word 
in  1864,  but  it  must  be  remembered  it  had  long  before  been  in  use  for  a 
different  purpose,  and  is  still  applied  by  medical  writers  in  its  original 
sense.  This  physiological  "  apnoea,"  then,  is  the  converse  of  dyspnoea, 
the  centre  resting  when  the  blood  is  more  arterialized,  and  being  stimu- 
lated when  it  is  more  venous.  The  stimulus  is  the  want  of  oxygen,  not 
excess  of  carbonic  acid,  because  dyspncea  is  produced  in  an  atmosphere 
of  nitrogen  in  which  there  is  no  impediment  to  the  exit  of  carbonic  acid, 
and  that  gas  does  not  accumulate  in  the  blood.  So,  too,  breathing  an 
atmosphere  containing  much  carbonic  acid,  but  at  the  same  time  more 
than  the  normal  percentage  of  oxygen,  does  not  produce  true  dyspnoea, 
but  only  narcotic  poisoning.  It  may  be  admitted  that  the  state  of  the 
blood  may  affect  to  some  extent  the  peripheral  ends  of  afferent  iierves, 
and  that  impulses  thus  started — as,  indeed,  impulses  started  in  any  way — 
may  contribute  indirectly  to  the  result  ;  but  the  effect  is  produced  mainly 
by  the  direct  action  of  the  blood  on  the  respiratory  centre,  for  when  the 
cord  is  cut  below  the  medulla,  and  both  vagi  also  divided,  defective  aera- 
tion still  causes  increased  activity  of  the  centre,  as  shown  by  the  facial, 
respiratory  movements.  Again,  if  we  cut  off  the  blood-supply  from  the 
medulla  by  tying  the  vessels  dyspnoea  is  produced,  though  the  blood  is 
not  altered  generally,  but  there  is  a  deficiency  of  oxygen  in  that  region 
with  accumulation  of  carbonic  acid.  So,  if  the  blood  in  the  carotids  be 
warmed  the  same  effect  follows,  viz. :  dyspnoea,  the  heated  blood  appar- 
ently hurrying  on  the  activity  of  the  cells,  so  that  the  normal  supply 
does  not  suffice. 

We  have  spoken  of  the  respiratory  centre  as  a  fact,  but,  though  gen- 
erally admitted,  its  existence  is  strenuously  denied  by  Brown-Sequard, 
who  says  he  has  seen  respiration  continue  after  removal  of  the  supposed 
centres,  and,  indeed,  of  the  whole  medulla,  and  his  statements  have  been 
corroborated  by  P.  de  Rokitansky,  Langendorff,  Nitschmann,  and  others. 
Not  long  ago  Langendorff,  as  the  result  of  a  lengthy  research,  expressed 
himself  as  disposed  to  completely  decentralize  the  respiratory  motor  im- 
pulses, but  the  most  recent  experimenter,  Dr.  Leon  Fredericq  {Archiv. 
fur  Physiologic,  1883),  finds  himself  compelled  to  admit  the  existence 
of  a  central  organ  for  respiratory  impulses  in  the  medulla  oblongata. 


CHAPTER  IV. 

FOOD    AOT)    DIET— THE    PROXIMATE    PEINCIPLES     OF    FOODS— 

FOOD-STUFFS. 

As  the  one  thing  which  is  necessary  to  be  supplied  frequently,  food 
should  take  a  first  place  in  therapeutics.  There  is  no  question  about  our 
power  to  regulate  or  to  arrest  the  supply  ;  we  can  cut  off  all  food  for  a 
time  or  we  can  diminish  it.  On  the  other  hand,  we  can  supply  it  more 
freely,  but  in  this  case  we  may  not  be  able  to  assist  its  assimilation  ;  often 
appetite  fails,  and  then  we  may  feel  that  we  are  in  the  position  of  the 
man  who  took  his  horse  to  the  brook  but  could  not  make  him  drink. 
The  arrest  of  supply,  a  fast,  is  a  most  powerful  therapeutic  agent.  Fur- 
ther, we  can  regulate  diet  in  reference  to  its  various  ingredients ;  we  can 
exclude  some  constituents  and  introduce  others.  The  substances  we  use 
as  food  are  so  numerous  that  to  simplify  their  grouping  we  employ  their 
proximate  principles,  which  are  either  organic  or  inorganic — the  latter 
class  comprising  water  and  salts. 

The  organic  elements  of  the  food  were  divided  by  Liebig  into  two 
classes  : 

I,  Plastic,  or  proteinaceous,  comprising  nitrogenous  substances,  which 
he  held  were  alone  concerned  in  repair,  growth,  nervous  and  muscular 
energy. 

II.  Elements  of  respiration,  afterward  better  styled  calorifacient  prin- 
ciples, comprising  the  organic  non-nitrogenous  substances  which  he  con- 
sidered were  employed  in  heat  production. 

No  doubt  a  very  direct  relation  exists  between  nitrogenous  food  and 
muscular  work,  but  that  it  must  be  converted  into  tissue  before  it  can 
liberate  force  has  not  yet  been  proved.  It  has,  in  fact,  been  shown  that 
heavy  labor  can  be  undergone  for  a  short  period  on  a  non-nitrogenous 
diet. 

Prout  took  milk  as  the  type  of  a  perfect  food,  and  no  one  will  deny 
that  it  is  so  for  the  young,  who  both  subsist  and  grow  upon  it  alone,  and 
flourish  best  when  nothing  else  is  added  to  it.  The  ingredients  of  milk 
are  :  (a)  nitrogenous  ;  (b)  fatty  ;  (c)  saccharine  ;  (d)  mineral — and  we 
cannot  do  much  better  than  follow  this  classification  with  a  little  enlarge- 
ment. 


22  THERAPEUTICS    OF   THE    KESPIRATORY    PASSAGES. 


I. — Nitrogenous,  Plastic,  oe  Albuminous  Foods. 

These  are  of  two  varieties  : 

A.  Substances  containing  nitrogen  in  the  same  proportion  as  albu* 
men,  viz,  :  two  of  nitrogen  to  seven  of  carbon,  nearly.  These  substances 
are  sometimes  called  albuminates,  and  this  group  includes  albumen,  fibrin, 
syntonin,  myosin,  globulin,  and  casein,  from  the  animal  kingdom,  with 
glutin  and  legumin  from  the  vegetable.  Their  work  is  tissue  repair, 
regulation  of  oxygen,  absorption,  and  utilization  ;  under  special  circum- 
stances they  may  form  fat  and  liberate  energy. 

B.  Substances  containing  nitrogen  in  the  proportion  of  two  to  five  and 
one-half  of  carbon,  or  four  to  eleven.  This  class  comprises  gelatin, 
chondrin,  keratin,  ossein,  etc.  These  perform  similar  functions  under 
particular  circumstances,  but  far  less  perfectly.  Some  have  doubted 
whether  they  possess  any  nutritive  value  at  all.  The  experiments  of 
Pettenkofer  and  Voit,  of  PIosz  and  Gyorgyai,  Maly,  Latschenberger,  and 
others  appear  to  indicate  that  the  gelatinoids  cannot  replace  the  albu- 
minoids in  the  formation  of  tissues,  although  they  may  be  perhaps  sub- 
stituted for  metabolism. 

Nitrogen  is  present  in  every  tissue  which  can  liberate  any  form  of 
energy,  and  seems  to  be  necessary  for  its  manifestation,  even  if  it  only 
serves  as  an  instrument.  Nerves,  muscles,  gland-cells,  the  cells  sus- 
pended in  liquids,  all  are  nitrogenous.  So,  too,  are  the  digestive  liquids  ; 
the  ferments  contained  in  these  liquids,  ptyalin,  pepsin,  pancreatin,  are 
nitrogenous — so  are  biliary  compounds.  Cut  off  the  nitrogen  from  the 
food  and  function  languishes,  not  at  once,  perhaps,  but  as  soon  as  the 
store  in  the  body  is  exhausted.  We  may  add  that  the  nitrogenous  food- 
stuffs are  not  completely  exhausted  of  their  energy  in  the  body  ;  the 
chief  product  of  their  combustion,  urea,  carrying  away  about  one-seventh 
part  of  the  potential  energy.  Voit's  experiments  seem  to  show  that 
albumen  is  perhaps  accumulated  in  the  general  fluids  of  the  body,  from 
which  it  is  taken  for  the  repair  of  the  tissues  as  they  may  require  it,  and 
that  this  dissolved  albumen  is  more  easily  metabolized  than  that  which 
has  become  tissue.  A  full  supply,  perhaps  an  excess,  of  such  dissolved 
albumen  is  essential  to  healthy  functional  activity  ;  but  further  excess  is 
at  once  metabolized.  Thus  the  excretion  of  nitrogen  depends  on  the 
amount  in  the  food  and  not  on  muscular  exertion,  as  Liebig  thought.  In 
support  of  the  more  recent  view,  it  may  be  remarked  that  the  metabolism 
of  albuminoids  is  never  entirely  suspended,  nor  is  it  increased  by  exer- 
cise, which,  however,  as  previously  proved  by  Dr.  Edward  Smith,  enor- 
mously increases  the  excretion  of  urea. 

We  pass  on  now  to  the  next  class. 


FOOD    AND    DIET.  23 


II. — NoN-NlTBOGENOUS. 


These  consist  of  hydrocarbons  or  fats  and  carbo-hydrates  of  starches 
and  sugars,  to  which  we  may  add  vegetable  acids  and  pectous  substances. 

A.  Fats  or  hydrocarbons  are  composed  of  carbon,  hydrogen,  and 
oxygen  ;  the  oxygen  being  insufficient  to  combine  with  all  the  hydrogen 
in  order  to  form  water.  The  unoxidized  hydrogen  is  in  the  proportion  of 
about  one  to  seven  of  the  carbon.  The  fats  are  more  energetic  as  calori- 
facients  than  the  amyloids,  about  two  and  a  half  times  as  effectual,  and 
they  are  also  of  value  as  nutrients,  especially  of  the  nervous  system,  and 
no  doubt  help  in  the  production  of  energy.  Perhaps,  also,  they  assist 
disintegration.  Fat  is  always  present  in  the  nerve-tubules  and  in  the 
ganglionic  centres.  It  is  also  of  some  use  in  digestion,  perhaps  aiding 
the  solution  of  proteids  ;  further,  it  seems  to  assist  in  their  conversion  into 
tissue.  Even  artificial  digestion  is  hastened  by  the  presence  of  fat,  and 
it  has  been  proved  experimentally  that  albuminous  food  deprived  of  all 
fat  lies  longer  in  the  stomach.  The  power  of  the  pancreatic  fluid  is 
largely  expended  in  emulsifying  fats,  and  chymification  and  absorption 
into  the  blood  are  thus  secured.  It  would  appear  that  the  white  corpus- 
cles get  their  first  impulse  from  fat,  which  thus  directly  helps  to  make 
blood,  and  it  seems  to  have  something  to  do  in  cell  development.  If, 
then,  fat  promotes  digestion,  chymification,  the  absorption  of  nutrient 
fluids,  and  their  transmutation  into  blood,  or  rather  corpuscles  ;  and,  fur- 
ther, seems  to  enter  cells  and  take  a  part  in  the  process  by  which  the  nu- 
trient juices  derived  from  the  blood  become  tissues,  and  afterward  assists 
the  disintegration  and  removal  of  used-up  material,  it  is  not  surprising 
that  a  deficiency  of  this  aliment  should  prove  disastrous,  and  that  in 
some  diseases  characterized  by  malnutrition,  the  administration  of  easily 
digestible  fats  should  prove  our  most  valuable  therapeutical  resource. 
Cod-liver  oil  is  thus  an  important  aliment  as  well  as  a  medicine. 

B.  Carbo-hydrates  or  amyloids  may  fairly  be  called  hydrates  of 
carbon,  as  their  oxygen  and  hydrogen  are  in  the  proportion  to  form 
water.  The  proportion  of  water  to  carbon  is  about  three  to  two.  These 
substances  are  the  starches  and  sugars.  They  are  converted  into  fats  by 
deoxidation  and,  as  we  have  seen,  they  also  give  rise  to  energy  and,  of 
course,  supply  animal  heat.  Dextrin  is  included  in  this  group,  though 
the  proportion  of  oxygen  and  hydrogen  is  not  precisely  the  same.  Cel- 
lulose, from  its  form  and  aggregation,  is  only  adapted  for  animals  with 
an  appropriate  digestive  apparatus.  As  the  amyloids  are  so  closely 
related  to  the  fats,  it  is  natural  to  inquire  whether  the  former  can  alto- 
gether replace  the  latter.  Certainly  not  conveniently,  and  as  a  matter 
of  taste  alone  the  human  race  has  always  preferred  to  eat  both.  After 
long  discussions  it  is  now  admitted  that  fat  may  be  derived  from  carbo- 


24  THERAPEUTICS    OF   THE   EESPIRATORY    PASSAGES. 

hydrates.  A  man's  living  on  fat,  free  diet,  proteids,  amyloids,  salts,  and 
water  being  supplied,  would  seem  to  be  a  question  of  digestion,  though  a 
full  experiment  of  this  kind  has  not  been  made.  He  can  exist  for  a  time 
on  proteids,  fat,  salts,  and  water — but  health  is  not  sustained  on  such 
diet,  Parkes  found  in  some  experiments  that  when  the  health  failed 
under  certain  dried  foods,  it  was  at  once  improved  by  the  addition  of  fats 
and  amyloids  without  nitrogen.  It  would  seem  that  some  fat  may  be 
obtained  from  albuminates,  and  in  diabetes  sugar  seems  sometimes  also 
derived  from  them,  but  they  cannot  replace  either  sugar  or  starch,  as  the 
system  would  be  injured  by  the  excess  of  nitrogen  introduced.  We  con- 
clude, then,  that  a  due  proportion  of  all  classes  is  necessary  for  health. 

C.  Vegetable  Acids. — With  these  we  may  perhaps  associate  pectin 
and  its  allies.  In  this  group  the  oxygen  is  more  than  enough  to  com- 
bine with  all  the  hydrogen  as  water,  except  in  acetic  and  lactic  acids, 
in  which  there  is  no  excess.  They  furnish  but  little  energy  in  oxidation, 
but  being  converted  into  carbonates  assist  in  maintaining  the  alkalinity 
of  the  blood. 

III. — Inorganic  Substances. 

A.  Salts  are  essential  to  health,  they  seem  to  be  largely  concerned  in 
nutrition,  facilitating  the  removal  of  effete  matter  as  well  as  the  entrance 
of  nutrients.  Perhaps  they  promote  the  transmutation  of  liquid  colloid 
into  solid  tissues,  as  well  as  the  converse  solution  of  these.  They  seem 
to  be  concerned  in  digestion,  absorption,  assimilation,  sanguinification, 
and  tissue  building  ;  later  their  presence  promotes  disintegration,  secre- 
tion, and  excretion.  Proteids  are  incapable  of  osmosis,  but  the  salts  and 
diffusible  acids  aid  in  their  conversion  into  peptones.  An  opposite 
effect  may  be  produced  in  the  alkaline  blood  and  this  again  reversed  in 
the  acid  tissues.  As  to  disintegration,  acid  compounds  are  produced  by 
oxidation,  and  they  appear  to  give  to  the  salts  a  solvent  power  on  the 
debris.  Salts  have  also  been  regarded  as  regulators  of  energy  as  well  as 
nutrition,  and  some  of  them  give  solidity  to  bone,  etc.  A  few  words 
may  be  added  respecting  the  several  salts. 

Chloride  of  sodium  is  universally  recognized  as  of  great  importance. 
The  instinct  of  animals  as  well  as  of  the  human  race  shows  its  necessity. 
Feeding  his  victims  on  food  deprived  of  salt  was  once  one  of  "  man's  in- 
humanities to  man."  Almost  everywhere,  in  all  ages,  among  savages 
and  civilized  alike,  salt  has  been  regarded  as  an  emblem  of  wisdom,  riches, 
comfort,  and  even  immortalitv.  It  forms  about  half  the  weight  of  the 
salines  in  the  blood,  but  it  does  not  enter  into  the  tissues,  appearing  to 
act  rather  as  a  medium.  We  cannot  much  change  the  amount  in  the 
blood.  Dilute  solutions  run  off  by  the  kidneys,  concentrated  ones  by  the 
bowels  ;  thus  if  we  drink  sea-water  it  is  not  absorbed.    Most  unorganized 


FOOD    AND    DIET.  25 

and  waste  products  of  the  body  form  crystallizable  compounds  with  salt  ; 
possibly  this  is  why  it  seems  to  be  concerned  in  both  absorption  and  se- 
cretion. 

Phosphates. — Alkaline  or  basic  phosphate  of  soda  is  always  present 
in  the  blood,  but  acid  phosphate  of  potash  appears  in  the  flesh  ;  their 
functions  must  be  different,  and  in  some  degree  opposed.  The  alkalinity 
of  the  blood  keeps  the  fibrin  and  albumen  in  the  liquid  colloidal  state. 
The  basic  phosphate  of  soda  also  absorbs  carbonic  acid,  and  is  the  chief 
agent  for  its  removal,  acting  like  an  alkaline  carbonate  which  is  capable 
of  replacing  it  in  case  of  its  insufficiency.  In  the  herbivora  the  propor- 
tion of  these  two  salts  is  the  reverse  of  that  found  in  the  carnivora.  In 
fact,  we  may  say  that  whenever  sodium  phosphate  is  insufficient  in  quan- 
tity to  carry  away  the  carbonic  acid  it  is  supplemented  by  the  alkaline 
carbonate,  and  where  phosphoric  acid  is  deficient  it  is  replaced  by  car- 
bonic acid.  The  acid  phosphate  of  potash  in  muscular  substance  re- 
verses the  alkaline  action  of  the  blood,  promoting  the  transudation  of 
nutrient  material  as  well  as  the  solution  of  effete  matter.  Earthy  phos- 
phates, especially  the  lime-salt,  are  present  in  all  hard  tissues,  not  only  in 
the  bones  and  teeth,  but  also  in  the  flesh.  Possibly  their  presence  directly 
promotes  solidification  ;  they  appear  to  be  agents  in  cell-growth.  Lime 
is  present  in  morbid  growths  and  in  rapidly  growing  cells  in  considerable 
amount.  Weiske  found  that  when  calcium  phosphate  was  excluded  from 
the  food  of  a  goat  its  bones  did  not  lose  their  lime  ;  but  perhaps  it  was 
drawn  from  other  parts,  as  nutrition  was  evidently  interfered  with,  the 
animal  becoming  weak  and  dull.  Phosphorus,  like  sulphur,  is  thought 
to  enter  the  system  with  the  albuminoids. 

Iron  and  manganese  are  both  present  in  the  blood.  Iron  in  some 
form  is  further  necessary  for  the  coloring  matter  of  muscle,  and  in  some 
degree  is  found  in  almost  all  structures,  just  as  it  is  in  almost  all  foods. 
Manganese  is  the  chief  mineral  of  the  corpuscles  in  white-blooded  ani- 
mals as  iron  is  in  red-blooded.  In  haemoglobin  and  myochrome  the  iron 
is  combined  with  albumen,  or  rather  globulin.  They  absorb  oxygen  from 
the  atmosphere,  and  give  it  up  in  the  presence  of  reducing  agents.  The 
functions  of  the  iron  compound  are  therefore  respiratory,  they  are  pur- 
veyors of  oxygen,  taking  it  from  the  air  in  the  lungs,  carrying  it  thence 
over  the  whole  body  to  be  employed  in  oxidizing  tissue. 

Dr.  Edward  Smith  calculates  that  an  adult  man  needs  daily  from  32 
to  79  grains  of  phosphoric  acid,  from  51  to  175  grains  of  chlorine  =  85 
to  291  of  table-salt,  from  80  to  171  of  soda,  from  27  to  107  of  potash,  2.3  to 
6.3  of  lime,  from  2.5  to  3  of  magnesia,  which  last  is  also  an  essential  con- 
stituent of  some  tissues.  It  would  seem  that  only  a  small  proportion  of 
these  salts  is  stored  up  in  the  system,  for  Mr.  Lawes  found  in  fattening 
pigs  that  only  twelve  ounces  out  of  eleven  pounds  present  in  the  food 
were  retained,  and  this  amount  was  chiefly  earthy  phosphates.    Generally 


26  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

there  is  sufficient  saline  in  our  ordinary  food  and  drink,  except  of  sodium 
chloride,  and  to  supply  this  table-salt  must  be  added. 

B.  Water  is  necessary  in  large  quantities.  It  is  present  in  every 
tissue,  even  the  most  solid,  as  the  teeth  ;  it  forms  seventy-five  per 
cent,  of  muscle,  and  about  seventy  per  cent,  of  the  entire  weight  of  the 
body  ;  it  constitutes  79.5  per  cent,  of  the  blood.  Not  less  than  about 
thirty  pounds  pass  in  and  out  of  the  alimentary  canal  by  secretion  and 
absorption.  Bidder  estimates  that  28.6  pounds  of  chyle  and  lymph  pass 
daily  through  the  thoracic  duct,  a  quantity  equal  to  nearly  one-fifth  of 
the  body  weight.  Barail  reckoned  that  for  a  healthy  adult  the  average 
amount  introduced  per  day  in  the  food  and  drink  was  two  thousand 
grammes.  Some  water  also  appears  to  be  formed  in  the  body,  but  not 
more  than  perhaps  three  hundred  grammes,  many  experiments  and  obser- 
vations showing  an  excess  of  two  hundred  to  five  hundred  in  the  amount 
removed  over  that  introduced.  After  forming  part  of  the  solids  and 
fluids,  it  is  discharged,  according  to  the  researches  of  Valentin,  Labois- 
ier,  Seguin,  and  others,  by  four  channels,  viz.,  twenty  per  cent,  through 
the  lungs,  thirty  per  cent,  through  the  skin,  forty-six  per  cent,  by  the 
kidneys,  and  four  per  cent,  through  the  bowels.  The  uses  of  water  are 
obvious  :  it  dissolves  the  food,  carries  it  into  the  circulation,  and  dis- 
tributes it  through  the  body  ;  it  combines  with  all  the  tissues  and  lubri- 
cates every  part  ;  it  dissolves  the  waste  and  carries  that  away  ;  thus  we 
see  it  is  an  active  agent  in  absorption  and  secretion,  in  construction  and 
destruction.  Besides  this,  it  regulates  the  temperature  as  it  evaporates 
from  the  skin  and  lungs.  Its  quality  is  important  ;  it  carries  into  the 
system  minerals,  as  do  the  foods.  It  would  not  be  advisable  to  abandon 
our  ordinary  drinking-water  in  favor  of  distilled  ;  in  fact,  as  Letheby 
observed,  "  the  water  of  a  country  may  determine  the  diet  of  its  inhab- 
itants." "The  soft  waters  of  the  lakes  of  Scotland,  for  example,  may 
have  had  something  to  do  with  the  choice  of  brown  meal,  which  contains 
so  much  saline  matter  ;  and  but  for  the  calcareous  waters  of  Ireland  the 
potato  could  not  have  become  a  national  food."  Nevertheless  there  are 
times  when  we  may  be  glad  to  place  patients  on  distilled  water,  in  order 
that  it  may  carry  off  other  salts  from  the  body,  as,  for  example,  where 
there  is  a  tendency  to  deposit  calculi.  So  drinking  largely  on  the  one 
hand  or  a  so-called  dry  diet  on  the  other  become  important  therapeutical 
measures. 

Nutritive  Value  of  Foods. 

Animal  and  Vegetable  Diet. — The  amount  of  food  required  by  the 
body  varies  with  the  work  it  has  to  do  and  other  circumstances.  Fur- 
ther, the  proportions  of  the  several  classes  best  adapted  varies  with  the 
kind  of  work  required. 


.  .  FOOD    AND    DIET. 

The  following  table  gives  the  amounts  required  : 


'2i 


Subsistence. 

Best. 

Standard. 

Hard  work. 

Proteids 

Ounces. 
2.0 
0.5 

12.0 
0.5 

Ounces. 
2.5 
1.0 

12.0 
0.5 

Ounces. 
4.31 
3.53 

11.71 
1.70 

Ounces. 
6.0  to     7.0 

Fats 

3.5  to    4.5 

Amyloids 

16.0  to  18.0 

Salt 

1.2  to    1.5 

Total  water-free  food. . . 

15.0 

16.0 

21.25 

26.7  to  31.0 

The  amount  required  for  bare  subsistence,  that  is  for  the  maintenance 
of  the  internal  work  of  the  body  only  in  a  state  of  complete  repose,  is 
given  in  the  first  column.  But  as  a  man  could  probably  not  exist  on  that 
amount  without  loss  of  weight,  we  give  in  the  next  column  the  require- 
ments of  ordinary  rest,  which  presupposes  that  only  gentle  exertion 
should  be  undertaken,  and  is  the  minimum  for  an  adult  male  weighing 
150  pounds.  This  calculation  is  for  water-free  food,  that  is  each  constitu- 
ent is  reckoned  theoretically  as  water-free,  but  in  what  we  term  ordinary 
solid  food  there  is  from  one  hundred  to  one  hundred  and  fifty  per  cent, 
water,  so  that  thirty-two  to  forty  ounces  of  such  food  would  be  required. 
For  ordinary  work  a  larger  supply  is  needed  and  standard  daily  diets 
have  been  constructed,  partly  by  calculation  and  partly  by  experiments. 
We  give  the  mean  of  several  such  standard  diets  in  our  third  column,  but 
perhaps  this  should  be  a  little  more  liberal.  If  we  allow  twenty-three 
ounces  of  water-free  food  for  a  man  of  150  pounds,  this  gives  0.15  ounce 
for  each  pound,  or  nearly  one-hundredth  part  of  the  weight  of  the  body. 
This  is  dry  food,  and  would  correspond  with  fifty  to  sixty  ounces  of  ordi- 
nary solid  food,  to  which  may  be  added  the  fifty  to  eighty  ounces  of  water 
or  other  liquid  taken,  which  would  make  a  total  supply  of  seventy  to 
ninety  ounces  of  fluid  =  0.5  ounce  for  each  pound  of  the  body-weight. 
When  working  hard,  men  take  much  more  food  whenever  they  can  get 
it,  and  for  hard  labor  diet  the  greatest  increase  should  be  in  the  proteids 
and  fat.  Of  the  diets  given,  those  most  adapted  for  our  patients  would 
naturally  be  those  for  rest  and  ordinary  work,  but  as  some  patients 
imagine  they  ought  to  consume  large  quantities,  we  have  added  a  fourth 
column  to  our  table,  suitable  for  a  person  undergoing  very  laborious  work; 
it  gives  the  figures  calculated  by  the  late  Dr.  Parkes  as  sufficient  for  a 
soldier  on  service  in  the  field.'  Of  course  in  acute  cases  the  nature  of  the 
diet  may  have  to  be  greatly  changed — here  we  are  only  speaking  of  that 
which  is  required  in  health,  as  a  basis  for  the  consideration  of  what  may 
be  desirable  in  disease.  The  average  proportion  of  the  several  classes, 
taking  the  mean  of  the  figures  given  by  Moleschott,  Ranke,  and  Petten- 


28  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

kofer  and  Voit,  is  for  100  of  proteids,  83  fats,  273  amyloids,  and  23  salts. 
As  nutrition  depends  so  largely  on  the  chemical  interchanges  of  nitro- 
gen and  carbon,  many  calculations  and  experiments  have  been  made  as 
to  the  nutritive  value  of  different  foods.  In  the  best  diets  the  nitrogen 
should  be  in  the  proportion  of  one  to  fifteen  of  carbon.  Tables  based  on 
the  nitrogen  alone  lead  to  very  unsatisfactory  conclusions  ;  for  instance, 
ham  and  red-herring  would  be,  according  to  the  amount  of  nitrogen  con- 
tained, more  than  nine  times  as  nutritious  as  human  milk,  both  being  cal- 
culated in  the  dry  state.  In  framing,  therefore,  a  table  of  alimentary 
equivalents  we  must  consider  all  the  constituents.  The  late  Dr.  Letheby 
constructed  the  following  table  showing  the  percentage,  proportion  of 
nitrogenous  and  carbonaceous  matters,  the  latter  being  calculated  as 
starch. 

The  habits  and  instincts  of  the  human  race  are  in  favor  of  a  compara- 
tively rich  nitrogenous  diet,  and  the  easiest  to  digest  appears  to  be  one 
containing  meat  ;  for  though  the  chemical  composition  of  animal  and 
vegetable  albumen  is  nearly  the  same,  and  they  serve  similar  purposes,  the 
facility  of  digestion  is  not'to  be  overlooked.  A  judicious  admixture  of  meat 
and  vegetables  is  therefore  generally  recommended,  though  it  is  not  to  be 
denied  that  men  can  live  in  perfect  health  on  vegetable  food  ;  there  are, 
indeed,  races  who  do  this.  Some  advocates  of  animal  food,  however,  con- 
sider that  the  highest  kind  of  work  cannot  be  accomplished  on  such  a 
diet,  and  Dr.  Carpenter  must  perhaps  be  enumerated  among  these,  for  he 
sa^s  :  "  And  while,  on  the  one  hand,  it  may  be  freely  conceded  to  the  ad- 
vocates of  '  vegetarianism  '  that  a  well-selected  vegetable  diet  is  capable 
of  producing  (in  the  greater  number  of  individuals)  the  highest  jihi/sical 
development  of  which  they  are  capable,  it  may,  on  the  other  hand,  be  af- 
firmed with  equal  certainty  that  the  substitution  of  a  moderate  propor- 
tion of  animal  flesh  is  in  no  way  injurious,  while  so  far  as  our  evidence 
at  present  extends,  this  seems  rather  to  favor  the  highest  mental  devel- 
opment." Dr.  Graily  Hewitt,  in  his  address  at  the  British  Medical  As- 
sociation, assigned  to  a  defective  meat  diet  a  large  amount  of  "  weakness  " 
which  he  found  prevalent  and  regarded  as  an  antecedent  of  distinct  dis- 
ease, and  the  Lancet  recently  stated  that  three- fourths  of  a  pound  of  meat 
fairly  represents  the  daily  quantity  which  suffices  to  maintain  an  adult  in 
health.  Certainly  many  exceed  this,  taking  meat  two  or  three  times  a 
day,  even  when  leading  sedentary  lives,  but,  as  the  same  writer  points  out, 
sooner  or  later  they  pay  the  penalty.  On  the  other  hand,  many — especi- 
ally women — reduce  their  meat  to  a  minumum,  scarcely  taking  an  average 
day's  allowance  in  a  week,  and  it  may  easily  be  understood  that  they  do 
not  possess  the  same  vigor  as  those  who  take  more  ;  but  the  question 
naturally  arises  whether  these  persons  are  not  underfed  in  other  articles 
also,  and  that  their  weakness  is  due  not  so  much  to  want  of  meat  as  to 
want  of  food. 


FOOD    AND    DIET. 


29 


Table  of  the  Nutritive  Values  of  Food  (Dr.  Letueby). 


Bread 

Wheat  flour  . . . . 
Barley  meal. . . . 

Oat  meal 

Rye  meal 

Indian  meal  .. . . 

Rice 

Peas 

Arrowroot 

Potatoes 

Carrots 

Parsnips 

Turnips 

Sugar 

Treacle 

New  milk 

Cream 

Skim  milk 

Butter  milk .... 
Cheddar  cheese . 
Skim  cheese  . . . 

Lean  beef 

Fat  beef 

Lean  mutton  . . . 
Fat  mutton  .... 

Veal 

Fat  pork 

Green  bacon. . . . 
Dried  bacon. . . . 

Ox  liver 

Tripe 

Poultry 

White  fish 

Eels 

Salmon 

Entire  egg 

White  of  egg  . . . 
Yolk  of  egg  , . . . 
Butter  and  fats. 
Beer  and  porter. 


TOTAI, 

°i 

Total 

PEB  CEST. 

PER  CENT. 

u 

a; 

1 

a 

■£ 
to 

3 
01 

*2 

a 

"a 

to 

a 

0) 

tB    . 
O  on 
t-  ? 

-A 

z   w  p 

it 

li 

O 

g 

til 

p 

2 

i  ° 
< 

37 

8.1 

47A 

3.6 

1.6 

3.3 

8.1 

55.00 

6.8 

1.25 

28.21 

15 

10.8  66 

.3 

4.2 

3.0 

1.7 

10.8 

75.50    7.0 

1.66 

38.57 

15 

6.369 

.4 

4.9 

3.4 

3.0 

6.3 

80.3012.8 

0.97 

36.61 

15 

13.6  58 

.4 

5.4 

5.6 

3.0 

13.6 

77.80 

6.2 

1.94 

40.44 

15 

8.069 

.5 

3.7 

3.0 

1.8 

8  0 

78.30 

9.8 

1.33 

38.48 

11.164 

.7 

0  4 

8.1 

1.7 

11,1 

85.35 

7.7 

1.71 

43.09 

13 

6.3  79 

.1 

0.4 

0.7 

0.5 

6.3 

81.35 

12.9 

0.97 

39.03 

10 

23.0  55 

.4 

2.0 

2.1 

3.5 

33.0 

62.65 

2.7 

3.54 

38.55 

18 

.  ^ 

82 

.0 

83.00 

36.44 

75 

3.1 

18 

.8 

3.2 

6.3 

6.7 

2.1 

22.50 

10.7 

0  31 

10.98 

83 

1.3 

8 

.4 

6.1 

0.3 

1.0 

1.3 

15.00 

11.5 

0.20 

7.28 

82 

1.1 

9 

.6 

5.8 

0.5 

1.0 

1.1 

16.65 

15.1 

0.17 

7.91 

91 

1.3 

5 

.1 

3.1 

0.6 

1.2 

7.20 

6.0 

0.19 

3.76 

5 

95.0 

95.00 

42.22 

23 

77.0 

77.00 

34.22 

86 

4.1 

5.3 

3.9 

0.8 

4.1 

14.95 

3.6 

0.63 

8.55 

66 

2.7 

3.8 

36.7 

1.8 

3.7 

69.55 

25.7 

0.42 

32.17 

88 

4.0 

5.4 

1.8 

0.8 

4.0 

9.90 

2.5 

0.62 

6.26 

88 

4.1 

6.4 

0.7 

0.8 

4.1 

8.15 

2.0 

0.63 

5.53 

36 

28.4 

31.1 

4.5 

38.4 

77.75 

3.7 

4.37 

47.77 

44 

44.8 

6.3 

4.9 

44,8 

15.75 

0.3 

6.90 

37.82 

73 

19.3 

3.6 

5.1 

19.3 

9.00 

0.5 

2.97 

12  98 

51 

14  8 

39.8 

4.4 

14.8 

74.50 

5.0 

2.28 

39.99 

72 

18.3 

4.9 

4.8 

18,3 

12.25 

0.7 

2.82 

13.95 

53 

12.4 

31.1 

3.5 

13.4 

77.75 

6.3 

1.91 

40.33 

63 

16.5 

15.8 

4.7 

16.5 

39.50 

2.4 

3.54 

25.22 

39 

9.8 

48.9 

3.3 

9,8 

132.25 

12.5 

1.51 

58.89 

24 

7.1 

56.8 

3.1 

7.1 

167.00 

23.5 

1.09 

77.52 

15 

8.8 

73.3 

2.9 

8.8183.85 

20.8 

1.36 

85.53 

74 

18.9 

4.1 

3.0 

18.9 

10.25 

0.6 

2.91 

13.34 

68 

13.2 

16.4 

2.4 

13.3 

41.00 

3.1 

3.04 

24.36 

74 

21.0 

3.8 

1.2 

21.0 

9.50 

0.4 

3.23 

13.99 

78 

18.1 

3.9 

1.0 

18.1 

7.35 

0.4 

2.79 

11.64 

75 

19.9 

13.8 

1.3 

9.9 

34.50 

3.5 

1.53 

19.93 

77 

16.1 

5.5 

1.4 

16.1 

13.75 

0,8 

3.48 

13.60 

74 

14  0 

10.5 

1.5 

14.0 

36.25 

1.9 

2.16 

18.18 

78 

20.4 

1.6 

20,4 

3.14 

9.49 

53 

16.0 

30.7 

1.3 

16.0 

76.75 

4.8 

2.46 

41.55 

15 

. 

83.0 

2.0 

207.50 

92.22 

91 

0.1 

i 

i.7 

•• 

0.2 

0.1 

8.70 

87.0 

0.02 

3.92 

'  The  available  carbon  consists  of  all  the  carbon  of  the  carbonaceous  constituents  of 
the  food,  and  of  the  carbon  of  the  nitrogenous  after  deducting  the  carbon  of  the  urea 
which  is  excreted,  100  of  dry  nitrogenous  matter  yielding  31.23  urea. 


30  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

The  advocates  of  meat  diet  say  that  the  carnivora  are  more  active,  or 
at  any  rate  that  they  can  respond  to  sudden  calls  for  exertion  more  easily 
than  the  herbivora.  But  we  must  not  be  content  to  contrast  the  sudden 
spring  of  the  tiger  with  the  slow  steady  move  of  the  domesticated  cow. 
The  antelope  will  start  with  amazing  rapidity  and  keep  up  its  run  for  a 
great  distance.  The  high-bred  hunter  and  the  plodding  donkey  are  both 
vegetable-feeders.  The  carnivora  appear  to  be  fiercer  in  their  nature, 
but  that  would  be  almost  necessary  to  enable  them  to  seize  their  prey. 
It  is  said  that  the  acorn-eating  bears  of  India  and  America  are  mild  and 
tractable,  while  the  flesh-eating  polar-bears  are  savage  and  untamable. 
Experiments  have  been  made  by  feeding  bears  on  different  diet,  and 
these  point  to  the  same  conclusion,  but  allowance  should  be  made  for  ani- 
mals kept  in  captivity.  Men  also  seem  to  differ  somewhat  in  their  dis- 
position and  powers  of  endurance  according  as  they  live  on  vegetable 
diet  or  partake  of  meat.  Hindoo  navvies  employed  in  the  boring  of 
tunnels  have  felt  driven  to  forsake  their  vegetable  diet  and  live  like  their 
English  fellow-laborers.  Liebig  attributed  the  Englishman's  energy  to 
the  nature  of  his  food,  and  says  :  "  Compare  the  English  statesman,  who, 
in  expounding  his  views  or  maintaining  a  debate  in  Parliament,  delivers 
a  speech  lasting  five  hours  or  more,  who  at  sixty  years  of  age  retains  the 
capability  of  taking  part  in  field  sports,  with  the  German  philosopher, 
who  at  the  same  age  keeps  up  with  difficulty  the  remains  of  his  power  in 
order  to  be  capable  of  work,  while  he  becomes  fatigued  by  a  walk  of  a 
few  hours."  It  is  a  flattering  picture,  and  in  the  present  day  we  may  see  a 
foremost  statesman  with  physical  energy  enough  to  amuse  a  leisure  hour 
by  felling  trees,  but  it  is  to  be  feared  that  the  average  Englishman  will 
not  be  able  by  any  diet  to  display  an  equal  amount  of  physical  and  intel- 
lectual energy.  Again,  it  may  be  remarked  that  not  only  sustained  work 
but  sudden  putting  forth  of  energy  is  seen  in  men  by  no  means  remarka- 
ble for  their  meat-eating.  Some  recent  statistics  seem  to  show  that  the 
English,  after  all,  are  not  such  large  meat-eaters  in  comparison  with  other 
nations  as  has  been  generally  thought.  Even  if  they  are,  they  are  cer- 
tainly not  more  warlike  nor  more  implacable  than  their  neighbors  ;  in- 
deed, not  a  few  are  disposed  to  grumble  at  John  Bull  as  having  grown 
slow  to  take  offence.  It  may,  then,  be  doubted  whether  the  deductions 
that  have  been  made  can  be  sustained.  Certainly,  the  contrast  with  an 
ill-fed  rice-eater  should  not  be  made,  but  with  a  well-fed  vegetarian,  who 
takes  full  supplies  of  corn  and  lentils  as  well  as  rice.  The  argument, 
from  the  degree  of  complication  of  the  alimentary  canal,  seems  rather  to 
belong  to  the  digestibility  of  the  food.  Further,  it  seems  certain  that 
different  nitros^enous  foods  have  varvinsf  nutrient  values.  Fibrin  and 
gelatin  are  not  meat  and  cannot  supply  its  place.  Majendie  found  that 
dogs  fed  on  raw  meat  alone  for  one  hundred  and  twenty  days  retained 
their  health,  while  three  times  the  amount  of  isolated  fibrin  was  insuffi- 


FOOD    AND    DIET.  31 

cient  to  preserve  life,  though  much  gelatin  and  albumen  were  given  at 
the  same  time.  The  glutinous  materials  of  wheat  and  barley,  though 
chemically  nearly  alike,  are  not  of  equal  nutritive  power.  With  regard 
to  the  non-nitrogenous  foods,  their  varying  value  for  nutrition  depends 
largely  on  the  digestibility.  Starches  seem  to  differ  much  in  this,  though 
all  of  them  have  to  become  sugar.  Yet  sugar  will  not  completely  replace 
starches  in  our  food  ;  though  perhaps  this  is  partly  a  matter  of  taste,  or 
it  may  very  well  be  that  cane-sugar  may  be  less  assimilable  than  that 
produced  by  the  action  of  ptyalin  on  starch.  As  to  hydrocarbons,  animal 
fats  are  more  easily  digested  than  vegetable  ;  some  with  great  flavor 
offend  the  palate  or  disagree  with  the  stomach.  Excess  of  any  of  the 
classes  of  food  may  pass  through  the  alimentery  canal  undigested. 


CHAPTER  y. 
PEEPAEATION  OF  THE  FOOD-STUFFS— DIGESTrVTE  FLUIDS. 

The  digestibility  of  articles  of  food  is  closely  related  to  their  physical 
properties  and  these  we  may  considerably  modify  by  cooking.  Dr. 
Beaumont's  experiments  on  Alexis  St.  Martin  will  be  remembered  by  our 
readers,  and  they  certainly  give  some  useful  indications,  but  his  tables 
have  been  so  often  quoted  that  it  is  unnecessary  to  repeat  figures  which 
may  be  so  easily  referred  to.  Moreover  the  variations  in  cooking  intro- 
duce difficulties.  It  would  be  well  if  the  light  of  science  could  be  re- 
flected in  the  kitchen.  Cooking  may  be  compared  to  some  of  the  opera- 
tions of  pharmacy,  and  it  is  as  important  that  food  should  be  well  cooked 
as  that  medicines  should  be  accurately  dispensed. 

It  is  obvious  that  the  food  should  bear  a  certain  relation  to  the  pro- 
cesses by  which  its  nutritious  elements  are  to  be  extracted.  We  can- 
not feed  on  the  proximate  principles  but  must  prepare  them  in  our  bod- 
ies. Milk  is  indeed  a  perfect  food  for  the  young,  but  adults  seem  to 
want  something  else.  It  may  therefore  be  left  to  the  edentulous  race 
which  some  whimsical  sophists  anticipate  will  succeed  us  to  prepare  a 
fluid  aliment  for  adults,  as  the  present  age  has  made  artificial  foods 
for  those  of  its  infants  who  are  unhappily  deprived  of  their  mother's 
milk. 

The  world  seems  content  to  employ  its  own  digestive  organs,  and  even 
those  who  are  no  gourmands  seem  to  have  no  desire  to  renounce  the 
pleasures  of  the  table.  Suitable  food  being  then  obtained,  to  what  pro- 
cesses is  it  subjected  ?  Berzelius  compared  digestion  to  rinsing.  The 
food  is  taken  into  and  passed  along  the  alimentary  canal,  being  detained 
at  intervals  while  various  digestive  liquids  are  poured  upon  it.  By  these 
the  nutritious  elements  are  dissolved  out  and  carried  into  the  system  as 
the  solvents  thus  loaded  are  reabsorbed.  The  amount  of  these  digestive 
liquids  is  often  unappreciated.  According  to  the  researches  of  Bernard, 
Bidder,  and  Schmidt  no  less  than  three  gallons  are  secreted  into  and  re- 
absorbed from  the  alimentary  canal  every  twenty-four  hours.  The  fol- 
lowing are  the  daily  proportions  of  the  several  digestive  fluids  and  of 
their  chief  constituents  : 


PREPARATION    OF   THE    FOOD-STUFFS.  33 

Amounts  of  Digestive  Fluids  Secreted  Daily,  and  the  Proportions  of 
their  Chief  Constituents. 

Solid  matters.  Active  principles, 

lbs.  grs.  grs. 

Saliva 3.53  231  116  of  ptyalin. 

Gastric  juice 14.11  2,963  1,482  of  pepsin. 

Pancreatic  juice 0.44  309  39  of  pancreatin. 

Bile 3.53  1,234  1,058  of  organic  ferment 

Succus  intestinalis 0.44  46  28  of  organic  ferment. 

Total 22.05  4,783  2,723  of  special  solvents. 

These  liquids  are  not  merely  solvents,  but  each  possesses  a  power  of 
changing  the  food  by  virtue  of  the  peculiar  ferment  it  contains.  Each 
not  only  dissolves  nutrient  principles  but  transforms  them. 

Saliva. 

This  secretion  is  slightly  alkaline.  Except  when  fasting  it  contains 
only  about  one  per  cent,  of  solid  matter,  but  half  of  that  consists  of  the 
nitrogenous  ferment  called  jO<ya^«n,  possessing  similar  properties  to  dias- 
tase, for  it  converts  starch  into  glucose.  Mialhe  called  it  animal  diastase, 
and  calculated  that  it  could  transmute  eight  thousand  times  its  weight  of 
starch  into  a  soluble  glucose.  It  is,  then,  as  a  first  stage  in  the  digestion 
of  starches  that  ptyalin  is  of  value,  for  it  has  no  action  on  proteids  or  fats. 
Rodents  and  animals  which  feed  on  woody  matters  have  large  salivary 
glands  and  prolong  the  contact  of  the  food  with  the  saliva.  Dogs  swal- 
low their  meat  without  mastication,  and  their  viscid  saliva  has  little  use 
e.xcept  as  a  lubricant.  In  horses,  oxen,  sheep,  and  cats  there  is  not 
enough  ptyalin  to  appreciably  convert  the  starch.  In  human  infants 
there  is  no  ptyalin,  showing  that  they  ought  not  to  have  starchy  food. 
In  the  adult  the  action  is  indubitable  ;  it  is  an  easy  experiment  to  show 
that  glucose  appears  in  a  solution  of  starch  after  it  has  been  held  a  mo- 
ment in  the  mouth.  Some  dextrin  is  mostly  found  also,  showing  that 
the  ptyalin  either  transforms  the  starch  into  dextrin,  and  then  that  into 
glucose,  or  else  that  it  first  splits  the  starch  into  glucose  and  dextrin,  and 
then  transmutes  the  latter  also.  It  would  seem  that  other  intermediate 
bodies  may  also  be  formed  as  an  erythro-  and  achroo-dextrin.  The 
close  analogy  between  ptyalin  and  diastase  has  led  to  the  use  of  the 
latter  as  an  amylolytic  /  for  example,  in  extract  of  malt  we  have  a  sub- 
stance, if  well  made,  rich  in  diastase,  therefore  possessing  the  property 
which  characterizes  ptyalin.  This  is  one  reason  for  the  use  of  that  ex- 
tract as  a  medicine,  but  it  is  also  a  nutrient  on  account  of  its  other  ingre- 
dients. When  administered  with  a  view  to  its  amylolytic  powers  it 
should,  of  course,  be  given  with  starchy  food. 
3 


34  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 


Gastric  Juice, 

As  soon  as  the  food  reaches  the  stomach  it  is  subjected  to  v^ry  dif- 
ferent changes — not  that  it  is  necessarily  ph;nged  into  a  flood  of  gas- 
tric juice,  but  that  acid  liquid  is  being  rapidly  secreted,  indeed,  has 
begun  when  the  food  was  in  the  mouth  and  perhaps  before  ;  for  we 
are  informed  that  the  strongest  juice  is  obtained  from  pigs  which  have 
been  kept  hungry  and  killed  just  after  being  excited  by  savory  food 
which  they  have  not  been  allowed  to  eat.  As  the  churning  movements 
of  the  stomach  proceed,  each  part  of  the  food  is  brought  into  contact 
with  the  acid-secreting  mucous  membrane.  Thus  the  contents  of  the 
stomach  increase  in  acidity  and  in  the  presence  of  acids  it  is  found  that 
the  action  of  ptyalin  on  starch  is  suspended.  The  most  important  con- 
stituent of  the  gastric  juice  is  another  ferment — 

Pepsin,  the  presence  of  which  was  first  indicated  by  Schwann,  who 
may  therefore  be  considered  its  discoverer,  though  Wasmann  first  sepa- 
rated it  in  a  comparatively  pure  state.  In  the  presence  of  an  acid,  pepsin 
converts  proteids  into  a  soluble  form  of  albumen,  the  albuminose  of 
Mialhe  or  the  peptone  of  Lehmann.  As  the  product  seems  to  differ 
somewhat  according  to  the  body  from  which  it  is  derived,  we  may  speak 
of  peptones  in  the  plural  as  we  do  of  proteids.  The  action  of  pepsin, 
like  that  of  ptyalin,  is  evidently  that  of  a  ferment  ;  it  facilitates  or  sets 
up  a  change  which  may  be  produced  in  its  absence  under  special  circum- 
stances and  it  is  not  exhausted  in  the  act  of  digestion.  Its  action  is  ar- 
rested when  the  liquid  becomes  saturated  with  peptones,  but  then  we 
have  only  to  dilute  the  fluid  and  the  process  immediately  recommences. 
Its  power  is  enormous  ;  Wasmann  found  an  acid  liquid  calculated  to 
contain  one  part  of  pepsin  in  sixty  thousand  would  dissolve  meat,  and 
Lehmann  found  one  hundred  parts  of  dog's  gastric  juice  would  digest 
five  of  coagulated  albumen.  The  acidity  of  natural  gastric  juice  is  equal 
to  ,03  per  cent,  of  hydrochloric  acid.  It  would  seem  desirable  that  ex- 
periments in  artificial  digestion  should  be  made  with  the  same  strength, 
though  it  is  not  uncommon  to  employ  a  much  more  acid  liquid.  Leh- 
mann held  that  lactic  acid  was  the  natural  one  and  that  the  best  proportion 
was  such  as  would  saturate  1.27  of  potash.  Other  acids — lactic,  butyric, 
phosphoric,  or  at  least  acid  phosphates — may  be  found  in  fresh  juice, 
and  may  be  made  to  serve  in  artificial  digestion,  but  not  so  effectually  as 
hydrochloric,  and  the  degree  of  acidity  which  answers  best  varies  with 
the  acid.  The  evidence  points  to  hydrochloric  as  the  chief  natural  acid 
and  the  proportion  is  so  constant  that  some  have  considered  that  a  kind 
of  compound  is  formed  which  they  speak  of  as  pepto-hydrochloric  acid. 
This  is  very  different  from  ptyalin,  which  only  needs  a  faint  alkaline 
liquid. 


PREPARATION    OF   THE   FOOD-STUFFS.  35 

The  action  of  pepsin  is,  then,  on  proteids,  which  it  converts  into  pep- 
tones. As,  moreover,  fats  and  starches  are  enveloped  in  proteids,  they 
are  loosened,  the  starch-granules  and  the  oil-globules  being  thus  set  free, 
but  for  further  changes  they  have  to  wait.  The  chyme  is  from  time  to 
time  squeezed  through  the  pylorus  and  may  even  be  accompanied  by  im- 
perfectly digested  lumps  of  solids.  That  which  most  resists  the  gas- 
tric juice  usually  tarries  longest  in  the  stomach. 

But  there  is  another  point  here:  peptones  and  sugars  are  remarkably 
diffusible,  they  easily  dialyze  ;  they  may  therefore  pass  at  once  into 
the  gastric  capillaries.  Chyme  taken  from  a  stomach  in  full  digestion 
gives  evidence  of  the  presence  of  some  parapeptone,  but  not  of  peptone  ; 
and  food  has  been  found  to  disappear  from  the  stomach  of  an  animal 
after  ligature  of  the  pylorus.  We  conclude,  therefore,  that  the  peptones 
are  absorbed  at  once  from  the  stomach. 

Mennet. — Gastric  juice  acts  on  milk,  but  there  seems  some  difference. 
It  precipitates  the  casein,  but  this  effect  is  not  due  to  acidity,  for  it  will 
do  so  after  it  has  been  neutralized.  It  is  scarcely  due  to  the  pepsin,  for 
Brucke's  preparation  will  not  act,  though  a  glycerine  extract  of  the  mu- 
cous membrane  will.  This  looks  as  if  another  ferment  might  be  present 
in  the  latter,  and  which  would  be  the  active  principle  of  rennet.  Dr. 
Roberts  calls  this  "  curdling  ferment." 

3Iucus-fernient. — It  would  seem,  too,  as  if  there  were  another  ferment 
located  in  the  mucus  of  the  stomach,  for  in  its  presence  the  gastric  juice 
is  able  to  convert  cane-sugar  into  grape,  and  the  ingestion  of  cane-sugar 
seems  to  provoke  secretion  of  mucus.  This  mucus-ferment  may  be  an- 
alogous to  ptyalin  but  is  not  identical. 

Qas. — A  certain  amount  of  air  is  carried  into  the  stomach  with  the 
food  and  saliva.  It  is  returned  having  mostly  been  deprived  of  its  oxy- 
gen, for  analysis  of  eructated  gas  give  only  nitrogen  and  carbonic  acid 
with  occasionally  a  trace  of  organic  material,  A  small  quantity  of  car- 
bonic acid  may  come  from  the  tissues  of  the  stomach,  but  most  must 
diffuse  from  the  blood,  while  the  nitrogen  is  derived  from  the  air  of  which 
the  oxygen  has  been  used.  In  flatulency  the  enormous  quantity  of  gas 
disengaged  is  chiefly  carbonic  acid,  and  where  can  it  come  from  except 
the  blood  ?  It  may  be  admitted  that  some  persons  have  acquired  a  trick 
of  swallowing  air  like  a  cribbing  horse,  but  in  such  cases  the  amount 
would  not  be  very  great.  Fermentative  decomposition  of  saccharine  food 
or  of  changed  amyloids  may  undoubtedly  set  up  flatulence  and  prove  a 
source  of  some  of  the  gas.  But  in  many  cases  the  stomach  is  again  and 
again  distended,  and  that  very  rapidly,  after  the  removal  of  large  quanti- 
ties of  gas.  I  have  seen,  when  the  epigastric  region  has  been  tense  as  a 
drum,  highly  tympanitic,  and  the  patient  suffering  agonies,  instantaneous 
relief  follow  rapid  removal  of  the  gas,  so  coniplete  that  percussion  elicit- 
ed no  evidence  of  its  presence,  and  yet  two  or  three  minutes  afterward 


36  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

the  distention  has  returned,  to  be  again  relieved  in  the  same  way,  and 
this  course  of  events  repeated  for  hours  together,  the  patient  suffering 
alternations  of  agony  and  ease. 

Pancreatic  Juice. 

After  passing  the  pylorus  the  chyme  has  to  mix  with  pancreatic  juice 
and  bile,  both  of  which  being  alkaline  tend  to  neutralize  it,  but  it  remains 
somewhat  acid  a  little  longer  and  has  been  found  so  much  lower  down, 
but  perhaps  it  might  have  been  reacidified.  The  conversion  of  amyloids, 
which  was  retarded  or  arrested  in  the  stomach,  is  carried  on  much  more 
actively  in  the  small  intestines,  chiefly  by  the  pancreatic  juice,  which 
contains  a  ferment  resembling  ptyalin  in  its  effect  on  starch  but  much 
more  energretic  and  with  a  much  wider  area  of  action.  This  ferment  has 
not  been  absolutely  isolated,  but  a  ver\'^  active  substance,  pancreatin,  is 
obtained  by  methods  such  as  are  employed  to  prepare  pepsin.  Pancre- 
atic juice  not  only  acts  on  amyloids,  which  is  its  most  characteristic  prop- 
erty, but  it  dissolves  proteids  and  converts  them  into  peptones,  and 
moreover  it  emulsifies  fats.  One  essential  distinction  between  peptic 
and  pancreatic  digestion  is  that  the  former  is  an  acid  and  the  latter  an 
alkaline  process  ;  reversing  this  condition  will  in  neither  case  arrest  the 
action,  and  further,  as  peptic  requires  a  particular  degree  of  acidity  for 
perfection  so  does  pancreatic  of  alkalinity.  The  .03  per  cent,  of  hydro- 
chloric acid  required  for  perfect  peptic  digestion  is  represented  by  one  per 
cent,  of  sodium  carbonate  for  pancreatic.  In  each  process  peptones  are 
produced  very  similar,  if  not  alike,  but  the  by-products  differ.  Instead  of 
parapeptone,  which  is  an  acid  albumen,  we  get  a  sort  of  alkali  albumen, 
and  it  seems  not  unlikely  that  the  first  action  of  pancreatic  juice  is  to 
convert  the  proteid  into  an  intermediate  body  between  ordinar\'  and 
alkali  albumen. 

In  the  pancreatic  digestion  of  proteids  two  crystalline  bodies,  leucin 
and  tyrosin,  appear,  and  the  amount  of  peptones  which  can  be  recovered 
shows  a  great  loss — a  loss  increasing  with  the  time  of  digestion,  and  far 
exceeding  that  in  peptic  digestion  ;  thus  a  considerable  amount  of  proteid 
is  so  completely  broken  up  as  to  be  a  proteid  no  longer.  Such  a  complete 
change  does  not  occur  in  peptic  digestion.  We  do  not  yet  know  in  what 
proportion  proteids  are  thus  hurried  into  crystallines,  nor  even  how  far 
pancreatic  digestion  goes,  nor  whether  peptones  are  formed  and  rapidly 
absorbed,  but  inasmuch  as  leucin  and  tyrosin  are  always  present,  we 
conclude  that  they  are  formed  in  normal  digestion,  and  it  has  been  con- 
jectured that  excess  of  proteid  food  is  hurried  on  to  this  later  stage. 
Tnclol  also  appears,  but  is  probably  due  to  decomposition  induced  by  the 
presence  of  organisms,  for  when  experimenting  with  fresh  juice  its  odor 
is  very  marked  and  the  mixture  swarms  with   bacteria,  but  when  well 


PREPARATION  OF  THE  FOODSTUFFS.  37 

prepared  pancreatin  is  employed  and  precautions  taken  to  exclude  atmo- 
spheric germs  there  is  no  odor,  although  carbonic  acid  and  nitrogen  are 
disengaged.'  Kuhne  found  no  indol  was  formed  in  the  presence  of  sali- 
cylic acid.  Fermentative  changes  may  be  set  up  in  the  small  intestines, 
and  not  improbably  a  little  sugar  is  converted  into  lactic  acid.  Perhaps 
when  excess  of  proteids  is  eaten  these  fermentative  changes  may  give 
rise  to  disorders  of  the  late  digestion,  especially  to  flatulence.  The  pos- 
sibility of  butyric  acid  fermentation  at  this  stage  is  also  interesting,  as 
suggesting  one  method  by  which  amyloids  may  possibly  become  fat. 
Pancreatic  juice  does  not  act  on  the  gelatins,  in  which  it  contrasts  with 
gastric  juice. 

On  fats  the  emulsifying  action  is  familiar  to  all,  but  besides  this  the 
pancreatic  juice  also  splits  some  neutral  fats  into  their  respective  acids 
and  glycerine  ;  when  an  alkali  is  present  these  fatty  acids  would  form 
corresponding  soaps,  and  this  is  no  doubt  one  of  their  uses.  It  is  only 
when  emulsified  that  fats  to  any  extent  enter  the  lacteals,  and  when  fat 
is  undigested  we  naturally  look  to  the  pancreas.  It  is  true  subsidiary 
structures  may  assist  or  replace  it,  as  the  duodenal  or  intestinal  juice, 
but  the  most  important  aid  is 


Bile. 

This  fluid  has  no  action  on  proteids:  with  free  fatty  acids  it  forms 
soaps.  It  has  a  slight  emulsifying  power  and  in  some  animals  will  con- 
vert starch  into  sugar.  Bile,  or  even  a  solution  of  the  biliary  salts  throws 
down  a  precipitate  from  chyme,  which  is  a  parapeptoiie  and  carries  down 
with  it  mechanically  the  pepsin,  so  that  the  supernatant  liquid  has  lost  its 
peptic  power  even  if  reacidified.  Though  peptic  acid  is  arrested  by  bile 
it  promotes  the  pancreatic  digestion  of  proteids  and  it  helps  the  digestion 
of  fats,  for  both  experiment  and  observation  show  that  the  passage  of 
fat  undigested  through  the  alimentary  canal  may  be  due  to  defect  of  bile 
as  in  obstruction  of  the  biliary  duct  as  well  as  to  deficiency  of  pancrea- 
tin. The  secretion  of  bile  is  singularly  irregular,  in  which  it  is  distin- 
guished from  the  other  digestive  fluids.  When  the  chyme  passes  by  the 
biliary  orifice  it  seems  to  cause  gushes  of  the  secretion,  which  precipitate 
parapeptone,  and  this  forms  a  lining  to  the  membrane  which  may  possibly 
prevent  a  too  rapid  passage  of  undigested  matter.  Recent  investigations 
confirm  the  idea  that  waste  materials  of  different  tissues  are  removed  in 
the  bile.  It  has  been  doubted  whether  biliary  matters  absorbed  by  the 
blood  again  pass  into  the  bile,  but  Scliiff  and  more  recently  Baldi  {Lo 
Sperimentale,  1883)  have  shown   that  the   liver  rather  than  the  kidneys 

'  Vide  Brownen :  Action  of  Digestive  Ferments  on  Food  and  Drugs.  Trans.  Brit. 
Pharm.  Conf. 


38  THERAPEUTICS    OF   THE    EESPIRATORY    PASSAGES. 

remove  biliary  matters  which  they  had  injected  into  the  stomach  and  also 
into  the  blood  direct.  This  secretion,  however,  presents  many  analogies 
with  that  of  the  kidneys;  both  essentially  depend  on  the  collective  waste 
of  the  system,  the  liver  having  a  special  excretory  faculty  for  the  biliary 
materials  and  the  kidneys  for  others.  The  irregularity  of  the  flow  of 
bile  is  also  interesting  in  reference  to  the  use  of  so-called  cholagogues. 
The  late  Dr.  Hughes  Bennett's  experiments  led  him  to  conclude  that  we 
have  no  agents  except  food  for  directly  stimulating  the  hepatic  secretion; 
Dr.  Rutherford,  however,  does  not  quite  confirm  this.  Neither  Schiff  nor 
Baldi  found  either  food  or  medicine  excite  the  flow,  but  nevertheless 
clinical  observers  are  well  aware  that  medicines  may  at  least  hurry  the 
secretion  along  the  intestine. 

Succus  Entericus. 

It  is  said  to  come  from  the  glands  of  Lieberkuhn,  but  much  uncer- 
tainty exists  as  to  its  source  as  well  as  to  its  action.  It  might  almost  be 
compared  to  laboratory  washings;  it  is  said  to  convert  proteids  into  pep- 
tones and  to  emulsify  fats,  but  both  these  actions  have  been  denied.  It 
is  also  said  to  change  cane  into  grape-sugar,  and  also  into  lactic  acid,  and 
this  last  into  butyric  acid,  disengaging  carbonic  acid  and  hydrogen.  Its 
most  characteristic  action  appears  to  be  reinforcing  pancreatine.  By  the 
time  the  contents  of  the  alimentary  canal  arrive  at  the  ileocfecal  valve 
they  have  been  largely,  if  not  entirely  deprived  of  their  nutritive  princi- 
ples; they  are  about  as  fluid  as  in  the  duodenum,  secretion  and  absorp- 
tion having  been  thus  far  about  equal.  After  passing  the  valve  they  be- 
come acid,  and  this  must  be  from  fermentative  changes,  as  the  secretion 
of  the  walls  continues  alkaline.  In  the  large  intestine  absorption  of 
water  and  some  soluble  constituents  goes  on  and  no  doubt  the  secretion 
has  still  some  influence.  Although  digestion  may  be  said  to  be  pretty 
well  finished  at  the  ileocaecal  valve  it  is  still  capable  of  continuing  ;  the 
contents  are  not  merely  residues,  but  to  some  extent  products  of  the  pro- 
cesses previously  carried  on.  They  contain  a  ferment  similar  to  pepsin, 
and  another  resembling  ptyalin  or  trypsin.  This  is  very  important  in 
relation  to  rectal  alimentation.  We  have  often  kept  patients  for  long 
periods  by  this  plan,  but  of  late  years  we  have  been  able  to  improve  the 
method  by  using  the  artificially  prepared  ferments.  Still  it  has  been 
experimentally  shown  that  not  only  peptones  and  sugar  but  albuminoids 
and  amyloids,  such  as  white  of  eggs,  casein,  and  starch,  have  been  ab- 
sorbed when  introduced  through  a  fistulous  wound,  and  we  know  clini- 
cally that  nutrient  injections  will  support  life ;  we  know,  too,  that  artifi- 
cially formed  peptones  are  nutritious,  for  dogs  fed  on  them  and  non-nitro- 
genous food  put  on  flesh. 


CHAPTER  VI. 
YAEIATIONS  IN  THE  DIGESTIVE  PEOCESS. 

Regarding  digestion,  then,  as  the  process  of  extracting  the  nutritious 
elements  from  the  food  by  means  of  fluids  of  various  qualities,  we  observe 
that  these  are  not  merely  solvents  but  change  insoluble  substances  into 
soluble.  Albuminoids  become  peptones,  amyloids  turn  to  sugar,  and  these 
two  readily  diffuse  into  the  circulation.  Fats  are  emulsified  or  split  up 
into  their  respective  acids  and  glycerine  and  a  portion  of  these  saponified  ; 
the  emulsified  fats  pass  into  the  lacteals.  Most  of  the  materials  for  nu- 
trition thus  enter  the  system  by  the  small  intestine,  some  by  the  lacteals, 
and  some  by  the  portal  vessels.  Most  of  the  fat  passes  through  the  lac- 
teals, but  some  soaps  have  been  detected  in  the  portal  blood  and  in  the 
thoracic  duct  after  a  meal,  but  the  quantity  is  small  and  though  some  fat 
is  introduced  in  the  form  of  soap  into  the  circulation,  this  is  altogether 
a  subsidiary  process,  for  the  digestion  of  fats  invariably  leads  to  their 
presence  in  portal  blood  and  still  more  in  the  lacteals. 

The  sugar  and  peptones  should  naturally  take  the  direct  way  of  the 
portal  blood  or  the  indirect  route  of  the  lymphatics  ;  perhaps  some  of  these 
may  accompany  the  fats  into  the  lacteals,  and  it  has  been  conjectured 
that  possibly  less  diffusible  proteids  may  also  find  access  in  this  way,  for 
example  casein  and  parapeptone.  There  is  this  difficulty  about  peptones 
— they  cannot  be  detected  in  the  general  circulation  nor  in  the  portal 
blood,  nor  yet  in  the  chyle  during  digestion.  They  vanish  !  It  looks  as  if 
they  must  be  taken  up  as  fast  as  they  are  formed  into  the  circulation,  and 
there  immediately  reconverted  into  albuminates.  As  to  sugar  it  seems 
to  go  both  ways,  for  some,  though  not  much,  is  found  in  chyle  as  well  as 
in  portal  blood  ;  but  we  cannot  say  which  way  the  bulk  goes,  nor  do  we 
know  whether  amyloids  all  become  sugar  or  whether  a  little  may  not  be 
transformed  by  the  fermentative  process  previously  described. 

But  the  elaboration  of  the  aliment  does  not  always  go  on  so  smoothly  ; 
disturbances  in  the  process  may  take  place  at  any  point  in  the  journey 
of  the  food  from  the  mouth  to  the  tissues.  And  the  disturbing  circum- 
stances may  concern  either  the  body  or  the  aliment. 


40  THERAPEUTICS    OF    THE    KESPIRATOKY    PASSAGES. 


A. — The  Body. 

Disturbances  occur  at  various  points,  for  example  in  the  stomach  the 
peptic  digestion  may  be  impaired  ;  in  the  small  intestines  the  pancreatic. 
We  may  have  indigestion  or  difficult  digestion  (a)  of  animal  food  ;  (b)  of 
fat,  in  which  case  meat  is  generally  omitted  from  the  diet  ;  (c)  of  amyloids 
and  of  sugar  ;  (d)  of  water — this  last  being  much  more  frequent  than  some 
have  supposed.  In  the  next  stage  absorption  may  be  interfered  with  at 
its  commencement,  or  now  and  then  the  thoracic  duct  may  be  obstructed. 
Besides  the  chemical  changes,  the  mechanical  movements  by  which  diges- 
tion is  promoted  may  be  interfered  with,  as  may  the  nervous  influences 
which  regulate  them  as  well  as  the  secretions.  To  secure  the  richness  and 
purity  of  the  blood  it  is  necessary  for  all  these  functions  to  be  carried  on 
regularly  ;  and  in  case  the  circulating  stream  becomes  deteriorated  it  can 
only  supply  inferior  digestive  fluids,  and  the  whole  system  will  suffer  from 
its  impoverishment,  while  the  newly  made  chyle  is  in  its  turn  deteriorated, 
and  thus  we  have  established  a  vicious  circle  in  which  one  part  of  the  or- 
ganism reacts  injuriously  upon  another,  and  is  for  that  reason  in  its  turn 
itself  injured. 

B. — Aliment. 

This  may  vary  in,  I.,  quantity  ;  or  in,  11.,  quality.      As  to 
I.  Quantity,  there  may  be,  1,  excess  ;  2,  deficiency.     As  to  excess  it 
may  be  (a)  occasional  ;   (6)  habitual. 

1.  Excess. — (a)  An  excessive  meal  may  not  be  digested,  it  is  heavy, 
but  some  articles  of  close  texture  will  give  a  sensation  of  weight  to  deli- 
cate stomachs  even  in  small  quantity.  Thus  an  ounce  of  plum-pudding 
may  seem  heavier  than  four  or  five  times  as  much  meat  or  custard. 
Sometimes  after  a  heavy  meal  the  stomach  strikes,  as  it  were — the  gastric 
juice  fails,  the  food  remains  undigested,  there  is  enibarras  gastrique,  the 
food  decomposes,  and  gases  are  set  free,  chiefly  carbonic  acid  with  some 
carburetted  hydrogen  and  sometimes  a  little  sulphide,  or  some  organic 
material  which  pollutes  the  breath  and  adds  to  the  distress.  Unless  the 
semi-putrid  mass  be  got  rid  of  by  vomiting  or  purging  feverish  symptoms 
are  set  up,  the  blood  is  poisoned,  and  jaundice  or  other  symptoms  occur. 
Certain  Roman  gluttons  well  understood  how  an  emetic  would  prevent 
such  consequences  of  too  heavy  a  meal.  Sometimes  the  food  passes 
through  the  alimentary  canal  undigested  or  partially  digested,  but  with 
less  irritation,  for  in  habitual  heavy  feeders  meat  fibre,  vegetable  fibre, 
starches  and  fats  are  all  found  in  the  faeces.  Although  there  may  be  no 
excess  in  the  food  actually  taken  in  twenty-four  hours,  it  may  happen  that 
at  some  period  of  the  day  the  amount  may  be  too  great  for  the  powers 
of  the  stomach,  because  the  meals  are  either  too  close  together  or,  on  the 


VARIATIONS    IN    THE    DIGESTIVE    PROCESS.  41 

other  hand,  too  far  apart ;  in  the  latter  case  the  appetite  and  capacity  of 
the  stomach  being  subjected  to  long  periods  of  repose  interrupted  by  dis- 
tention, 

(b)  Habitual  excess  may  occur  from  too  much  food  or  from  the  qual- 
ity being  too  nutritious.  Sometimes  imperfectly  digested  material  may 
pass  into  the  blood.  The  risks  of  too  much  nutriment  vary  with  the 
quality  of  the  food.  Excess  of  proteids  gives  rise  to  plethora,  congestion, 
and  perhaps  enlargement  of  the  liver.  If  much  exercise  be  taken  it  may 
be  burnt  off,  but  with  too  little  exercise  oxidation  is  deficient,  as  if  enough 
oxygen  for  the  proteids  was  not  absorbed,  and  then  some  products  not 
fully  changed  remain  in  the  system  and  cause  disturbance,  or  else  in 
passing  out  trouble  the  organs  by  which  they  are  removed.  Gout  is  one 
of  these  evils,  but  it  is  no  doubt  partly  due  to  taking  liquids  which  retard 
metabolism  as  well  as  indigestible  articles,  for  large  meat  eaters  often 
escape  gout  so  long  as  they  are  engaged  in  laborious  employments.  Ex- 
periment has  shown  that  excessive  proteids  without  other  food  produces 
in  a  few  days  fever,  diarrhoea,  and  albuminuria  with  great  depression,  the 
last  symptom  being  probably  the  effect  of  the  salts  in  the  meat.  In 
habitual  excess  of  fats  and  starch  the  results  differ,  attacks  of  acidity  and 
flatulence  are  common.  In  consequence  of  the  retarded  metabolisms  of 
nitrogen  corpulence  may  ensue  and  muscular  debility,  upon  which  the 
heart  may  suffer  and  saccharine  urine  may  be  present.  Lastly,  the 
meals  may  all  be  small,  but  if  they  are  too  numerous  there  is  excess. 

2.  Deficiency/. — Acute  starvation  is  best  studied  in  famines,  chronic  in 
the  underfed  poor.  The  effects  of  deficiency  of  the  various  principles 
has  not  received  so  much  attention  as  it  deserves.  Dr.  Parkes  kept  a 
man  for  five  days  on  fat  and  starch,  and  attempts  have  been  made  to 
feed  patients  with  rheumatic  fever  in  this  way,  but  the  removal  of  all 
nitrogen  soon  brings  about  great  depression  and  the  patients  need  to  be 
carefully  watched  or  exhaustion  will  follow.  When  the  deprivation  of 
proteids  is  incomplete  but  yet  considerable,  there  will  ensue,  although 
later,  debility  and  anfemia.  Amyloids  may  be  withheld  for  a  considerable 
time  if  fat  be  given,  but  if  both  fat  and  starch  are  withheld  a  few  days 
will  bring  about  illness  in  spite  of  a  full  supply  of  proteids.  Deficiency 
of  fat  gives  rise  to  malnutrition  in  various  forms,  and  total  deprivation  is 
dangerous.  Very  often  the  addition  of  fat  to  the  diet  or  the  introduc- 
tion of  oil  as  a  medicine  is  a  most  important  measure.  Deficiency  of 
salts  is  also  attended  with  ill  results. 

II.  Quality. — Improper  food  may  produce  the  effects  of  deficiency 
in  so  far  that  it  takes  the  place  of  more  nutritious  substances  ;  but  it 
may  prove  more  injurious  than  this,  or  even  than  excess.  Sometimes  it 
may  be  positively  poisonous.  Then  good  food  may  become  bad  by  keep- 
ing or  other  circumstances,  or  it  may  be  improperly  cooked  or  insuffici- 
ently masticated  ;  these  or  other  circumstances  may  render  it  indigestible. 


42  THERAPEUTICS    OF    THE    KESPIRATOEY    PASSAGES. 

Meal-times. — The  time  of  taking  food  and  its  distribution  in  appro- 
priate meals  deserves  a  word.  We  have  seen  that  the  stomach  may  be 
overloaded  at  one  time  and  starving  at  another.  Savages  will  take 
enormous  quantities  at  once,  when  they  can  procure  it,  and  starve  at  other 
times.  In  civilized  life  we  regulate  our  diet  with  advantage.  Taste  has 
much  to  do  with  this.  Three  meals  a  day  is  perhaps  the  most  simple  plan 
and  is  usually  adopted  in  hospitals  and  public  institutions. 

According  to  Dr.  Edward  Smith,  the  daily  distribution  of  the  food, 
supposing  a  physiological  diet  of  4,300  grains  carbon  with  200  grains  of 
nitrogen  to  be  taken,  should  be  somewhat  in  this  manner  : 

Helative  Proportions  of  Food  at  Different  3feals. 

Equal  to 

Carbon.       Nitrogen.     Carbonaceous.     Nitrogenous, 
grs.  grs.  ozs.  ozs. 

For  breakfast 1,500  70  6.G2  1.04 

For  dinner 1,800  90  7.85  1.34 

For  supper 1,000  40  4.52  0.59 

Total  in  the  day 4,300  200  18.99  2.97 

The  continental  plan  of  two  meals  daily  agrees  with  many,  and  affords 
the  advantage  to  some  people  of  having  all  their  work  between  them, 
but  the  interval  is  too  long  for  weakly  people  and  they  should  therefore 
take  a  light  luncheon  between  and  be  careful  to  avoid  overloading  the 
stomach  at  their  regular  meals.  The  times  of  the  meals,  as  well  as  the 
articles  of  the  diet,  may  often  be  adapted  to  the  age  and  constitution  of 
the  individual,  as  well  as  to  the  work  he  is  called  upon  to  perform. 

In  invalids  who  are  walking  about  we  may  vary  and  arrange  the  diet 
of  health,  keeping  to  regular  meals  and  taking  care  to  provide  particular 
proportions  of  the  different  classes  of  alimentary  principles.  The  digest- 
ibility of  the  food  is  in  such  cases  of  the  first  importance,  but  very  often 
when  we  are  desirous  of  improving  nutrition  we  are  defeated  by  failure 
of  appetite,  and  even  when  this  is  not  the  case  we  may  have  to  supple- 
ment ordinary  diet  with  articles  which  become  imperative  in  acute  dis- 
eases. In  these  last  meals  are  abandoned,  often  no  solids  can  be  given, 
the  patient  is  in  bed,  rest  is  imposed,  and  we  return  to  the  simplest  food 
— liquids.  Milk,  supplemented  perhaps  by  beef-tea,  broths  or  soups,  or 
in  other  cases  gruel,  so  lauded  by  Hippocrates  and  employed  ever  since, 
or  barle^'-water,  or  other  forms  of  light  nourishment,  afford  what  is  re- 
quired. Where  there  is  any  difficulty  about  the  digestion  of  these  they 
should  be  peptonized.  Milk  must  be  curdled  in  digestion,  but  when  con- 
siderable quantities  of  curds  are  thrown  up  it  shows  that  the  casein  has 
not  been  merely  coagulated  but  that  hard  masses  have  become  conglom- 


VARIATIONS    IN    THE    DIGESTIVE    PROCESS.  43 

erated.  Mixing  with  lime-water  or  soda,  or  peptonizing,  will  obviate  this 
inconvenience.  A  considerable  quantity  of  liquid  food  may  be  taken  in 
the  twenty-four  hours  when  it  is  given  in  very  small  quantities  but  very 
frequently.  Two  or  even  three  ounces  per  hour  is  often  easily  taken,  but 
every  two  hours  is  mostly  enough  to  attempt,  and  thus  it  is  easy  to  ad- 
minister a  pint  and  a  half  daily.  I  have  known  a  teaspoonful  of  liquid 
aliment  taken  every  five  minutes  for  days  together  with  the  very  best 
results. 


CHAPTER  YII. 

ALIMENTS  AS  EEMEDIES— NUTRIENTS  AND  ANALEPTICS. 

From  what  has  preceded  we  see  that  nutrition  demands  the  mainte- 
nance of  a  continual  balance  between  the  food-supply,  the  power  of  the 
system  and  its  work.  Another  balance  has  also  to  be  maintained  be- 
tween the  several  classes  of  alimentary  principles  or  food-stuffs,  and 
these  are  so  related  to  the  work  that  we  may  arrange  dietaries  by  vary- 
ing them  according  to  the  work  done.  Suppose,  then,  the  food  to  be  suf- 
ficient, a  due  proportion  of  the  food-stuffs  to  be  included,  further,  that 
digestion  in  every  stage  is  easy,  absorption  unimpeded,  and  the  blood 
continually  renewed  with  wholesome  material  :  this  implies  the  integrity 
of  the  presiding  nervous  influence,  vigor  of  the  circulation,  perfection 
of  mechanical  movements — a  chain,  any  link  of  which  may  be  weak. 
But  if  all  these  actions  are  normal  the  blood  is  renewed  by  the  fresh 
chyle,  reinforced  by  the  lymph  and  continually  poured  into  the  stream 
through  the  thoracic  duct.  Up  to  this  point  all  lias  been,  as  it  were,  ab- 
sorption from  the  outside,  but  the  blood  now  passes  through  every  tissue 
and  here  begins,  so  to  say,  a  pouring  out  of  the  nutritious  material  into 
the  intercapillary  spaces,  an  impoverishing  process  so  far  as  the  blood  is 
concerned  (and  the  same  holds  good  of  secretion),  but  a  nutritive  one 
as  to  the  tissues  ;  these  have  to  select  or  appropriate  from  the  nutritious 
plasma  each  what  it  wants.  A  kind  of  elective  affinity  may  be  said  to  ex- 
ist by  which  this  is  accomplished  ;  thus  the  tissues  leave  a  residual  liquid 
around  them,  which  is  next  returned  by  the  absorbent  system  to  the 
blood,  as  it  is  only  defective  by  the  ingredients  appropriated.  That 
which  is  not  absorbed  by  the  lymphatics,  together  with  the  effete  matter 
cast  off  by  the  tissues,  the  results  of  denutrition  or  oxidation,  constitute 
the  final  residue,  which  passes  into  the  venous  capillaries  by  diffusion  and 
gives  to  the  venous  blood  its  positive  characters.  The  products  of  denu- 
trition and  disintegration,  the  results  of  the  destructive  changes,  are 
carried  away  by  the  blood  to  be  eliminated  by  the  organs  set  apart  for 
this  purpose,  and  so  maintain  the  purity  of  the  blood.  Thus  is  main- 
tained the  everchanging  balance  between  repair  and  wear  and  tear,  or 
rather  renewal  and  waste.  These  continual  changes,  appropriation  or 
construction  on  the  one  hand,  rejection,  destruction,  and  removal  on  the 


ALIMENTS    AS    REMEDIES NUTRIENTS    AND    ANALEPTICS.       45 

other  hand,  must  keep  pace  with  each  other.  Too  rapid  removal  leads 
to  decrease,  too  much  renewal  to  increase  of  weight,  and  such  deviations 
affecting  parts  of  the  body  give  rise  to  atrophy,  hypertrophy,  and  other 
allied  conditions. 

Seeing  the  importance  of  these  changes,  can  we  influence  them  ? 
Can  we  hasten,  retard,  or  alter  them  ?  Unquestionably  yes.  Deviations, 
except  within  narrow  limits,  mean  disease.  We  see,  therefore,  diseases  of 
quickened  or  of  retarded  tissue-change,  or  other  forms  of  malnutrition. 
Our  therapeutics  must  be  directed  to  prevent  such  deviations  or  to  obvi- 
ate their  results.  Both  in  health  and  in  disease  we  may  promote  or 
hinder,  we  may  hasten  or  retard  these  changes,  and  that  from  either 
side.  Thus  we  may  stimulate  either  construction  or  destruction,  supply 
or  removal,  and  we  may  do  this  from  either  side.     Let  us  begin  with  the 

Promoteks  of  Construction. 

We  have  dwelt  so  long  on  aliment  and  digestion  because  the  promo- 
tion or  prevention  of  nutrition  is  fraught  with  such  important  conse- 
quences to  our  patient,  and  furnishes  us  with  our  most  potent  remedial 
measures.  To  prevent  or  retard  construction  we  have  only  to  intercept 
or  limit  the  food  supply.  When  no  aliment  is  taken  death  soon  occurs, 
but  when  only  little  is  taken  this  event  is  delayed.  A  compensatory 
process  occurs  in  the  lessening  of  destruction,  for  under*the  influence  of 
scanty  supply  the  body  relaxes  its  work,  a  retardation  of  tissue  changes 
ensues,  and  so  for  a  time  the  balance  may  be  redressed.  But  preven- 
tion, if  easy,  is  not  so  often  important  as  promotion.  How  can  this  be 
accomplished  ?  Simply  by  supplying  nutrients,  for  the  natural  stimulus 
to  nutrition  is  the  presence  of  the  needed  material,  just  as  healthy  blood 
calls  forth  the  action  of  the  heart.  So  abundance  of  plastic  matter  pro- 
motes nitrogenous  transformation,  and  excess  of  amyloids  and  fats  may 
lead  to  obesity.  We  vary,  then,  the  food  and  go  beyond  the  usual  range 
of  ordinary  diet  ;  we  administer,  as  we  say,  nutrients,  which  are  the  sup- 
porters of  metabolism,  and  when  imperfect  health  exists  they  are  true 
analeptics — restorers.  There  is,  indeed,  another  way  of  promoting  con- 
struction— an  indirect  way — and  that  is  by  hastening  destruction,  for  if  the 
organism  is  in  good  working  order  it  is  obvious  that  inasmuch  as  con- 
struction and  destruction  go  on  pmn  passii,  increase  of  the  latter  will  cre- 
ate a  demand,  for  renewal  and  repair  will  be  effected  from  the  fresh  sup- 
ply. In  health  this  is  what  takes  place  when  work  is  increased  but  the 
diet  not  restricted.  Work,  then,  exercise,  within  the  limits  adapted  to 
the  capacity  of  the  individual,  is  a  promoter  of  construction,  because  it 
hastens  destruction,  and  so  we  can  prescribe  exercise,  gymnastics,  and 
so  forth.  Further,  we  can  hasten  removal  through  the  various  excretory 
organs  by  stimulating  them  to  increased  action  :  many  of  our  evacuants 


46  THERAPEUTICS    OF    THE    EESPIRATORY    PASSAGES. 

may  thus  be  made  indirect  promoters  of  secretion  by  exciting  increased 
elimination.  Once  more,  not  only  may  we  hasten  secretions  and  remove 
them,  but  we  may  even  take  away  a  portion  of  the  nutrient  fluid  which 
has  been  prepared  and  will  of  course  have  to  be  replaced,  this  direct 
depletion,  or  blood-letting,  within  certain  limits  and  under  certain  cir- 
cumstances, becoming  thus  a  direct  promoter  of  construction.  But  of  this 
indirect  method  hereafter,  we  have  first  to  consider  the  direct  promoters 
of  construction. 

Nutrients. — a.  Milk,  as  itself  a  complete  food,  may  be  first  considered. 
We  have  already  seen  its  importance,  and  sometimes  even  in  chronic  cases 
an  absolute  milk  diet  is  employed.  Milk  cures  are  very  common  in  Svvitz- 
erland,  but  they  are  by  no  means  modern,  being  at  least  as  old  as  the 
time  of  Galen,  who  sent  his  scrofulous  patients  to  Stabia  to  undergo 
them.  In  early  phthisis,  or  rather  in  the  pre-tubercular  stage,  a  milk  cure 
in  a  mountain  resort  has  often  been  beneficial,  but  some  influence  must  be 
assigned  to  the  fresh  air  and  suitable  climate.  It  may  be  necessary  to  em- 
ploy alkalies,  as  already  mentioned,  to  facilitate  the  digestion  of  milk,  but 
a  simple  method,  and  often  completely  effectual,  is  to  dilute  it  with  water, 
hot  or  cold,  according  to  taste  and  season.  Aerated  waters  are  also  of 
great  use  for  this  purpose.  The  most  certain  mode,  however,  of  secur- 
ing its  digestion  is  to  peptonize  it.  Whey  is  sometimes  employed  ;  it 
contains  the  sugars  and  the  salts,  but  the  fat  and  casein  have  been  re- 
moved, consequently  it  is  a  very  fluid  but  only  slightly  nutritious  diet. 
Buttermilk  is  in  some  places  a  favorite  ;  in  it  the  sugar  has  been  con- 
verted into  lactic  acid,  and  the  butter  as  far  as  possible  removed.  Kou- 
miss is  a  pleasant  fluid  in  great  favor  on  the  Steppes  of  Russia,  prepared 
by  fermenting  mare's  milk.  It  therefore  contains  a  little  alcohol  and 
carbonic  acid  besides  butter,  casein,  milk  salts,  and  lactic  acid.  A  simi- 
lar fluid  is  now  prepared  from  cow's  milk  ;  it  is  very  easily  digested, 
makes  a  nutritious  liquid  which  is  agreeable  to  feverish  patients,  and  is 
almost  always  easily  digested.  Perhaps  some  of  the  fame  of  the  koumiss 
cure,  as  carried  out  in  Russia,  may  be  due  to  the  outdoor  life  in  the  sin- 
gularly pure  atmosphere  of  the  Steppes. 

b.  Beef-tea  contains  all  the  salts  with  a  little  albumen  and  gelatin, 
and  some  other  nitrogenized  material.  It  stimulates  the  nervous  system, 
but  it  is  not  so  important  a  nutrient  as  is  generally  supposed,  especially 
when,  as  is  too  often  the  case,  the  fibre  is  not  powdered  and  added  to  it  ; 
given  alone  it  stimulates  and  often  provokes  fever,  quickening  tissue 
waste  but  not  supplying  sufficient  for  repair.  Mixed  with  arrowroot  or 
other  starchy  food,  or  taken  alternately  with  milk,  it  is  much  more  valua- 
ble. Broths  and  soups,  to  be  really  useful,  ought  to  be  made  in  the  same 
way.  A  patient  ought  not  to  be  fed  on  proteids  alone,  or  even  on  pro- 
teids  and  fats,  but  some  farinaceous  food  should  be  added  to  them.  The 
salts  in  beef-tea  would  tend  to  hasten  waste.    It  will  be  seen  that  the  vari- 


ALIMENTS    AS    REMEDIES NUTRIENTS    AND    ANALEPTICS.       47 

ous  extracts  of  beef,  valuable  as  they  may  be  as  stimulants,  can  scarcely 
be  considered  nutrients.  Eggs  afford  the  means  of  adding  highly  ni- 
trogenous material  to  the  diet  and  can  generally  be  digested  in  convales- 
cence. 

c.  Fatty  JSfutrients. — In  respiratory  diseases  the  digestion  is  sometimes 
good  and  at  other  times  it  fails,  and  our  greatest  ditficulty  is  to  maintain 
nutrition.  In  acute  inflammation  a  fever  diet  may  be  necessary,  but  gen- 
erally more  nutrients  should  be  given  than  in  fevers.  In  chronic  diseases, 
especially  phthisis,  there  is  often  a  state  of  malassimilation,  in  which  indi- 
gestion of  fat  and  even  repugnance  to  it  is  prominent,  and  this  may  oc- 
cur before  the  phthisis  is  pronounced  and  be  a  sort  of  premonition  of  it. 
The  organs  apparently  cannot  easily  utilize  it,  and  the  question  is  whether 
we  can  induce  them  to  do  so.  Digestion  of  proteids,  perhaps,  goes  on 
well  enough,  and  this  supplies  a  blood  rich  in  albuminates,  consequently 
full  of  material  for  repairing  albuminous  structure — like  the  lungs.  It  is 
quite  conceivable  that  under  such  circumstances  excess  of  proteids  may 
be  taken,  and  that,  perhaps,  under  the  mistaken  notion  that  they  will  im- 
prove the  nutrition  and  arrest  emaciation.  Is  it  not  rather  possible 
that  the  presence  of  such  excess  may  irritate  the  lungs  and  excite  rapid 
cell-proliferation  ?  It  seems  sometimes  as  if  the  more  such  patients 
needed  fat,  the  more  they  disliked  it.  Some  may  be  taken  in  the  form  of 
milk,  more  in  cream,  clotted  cream,  or  butter  ;  but  to  digest  these  fresh  air, 
out-of-door  exercise  will  perliaps  be  necessary,  and  when  these  as  well  as 
fat  meat  are  eliminated  from  the  diet,  from  an  apparently  unconquerable 
repugnance,  our  difficulties  increase.  What  is  the  use  of  ordering  cod- 
liver  oil  for  a  patient  who  is  sickened  by  the  thought  of  butter?  Can  we 
present  oil  or  fat  in  a  form  which  can  be  taken  ?  Many  attempts  have 
been  made  to  disguise  the  taste  and  appearance.  We  have  seen  how  fat  is 
digested,  can  we  not  commence  the  process  ?  Will  emulsifying  it  answer  ? 
Very  often  yes.  Pancreatic  emulsion,  prepared  from  the  best  beef-fat  by 
means  of  pancreatin,  was  introduced  by  Dr.  Dobell  a  few  years  ago  and 
has  been  found  a  most  valuable  nutrient. 

d.  Farinaceous  and  Saccharine  Hutrients. — It  is  not  necessary  to 
mention  the  various  articles  of  this  kind  suited  to  invalids.  The  weakest 
of  them — rice-water,  barley-water,  gruel,  as  well  as  vegetable  juices  and 
fruits,  all  have  their  places  and  are  utilized  in  turn.  Ripe  fruits  contain 
from  ten  to  fifteen  per  cent,  of  solid  matter,  consisting  of  sugar,  free 
acid,  nitrogenous  substances,  and  salines.  Dried  fruits,  being  richer  in 
sugar,  are  more  nutritious.  An  attempt  has  been  made  to  feed  con- 
sumptive and  other  patients  exclusively  on  ripe  grapes.  This  grape- 
cure  can  of  course  only  be  carried  out  where  the  grapes  flourish,  and  the 
influence  of  fresh  air  and  climate  is  to  be  considered.  There  is  not  enough 
nitrogen  in  the  fruit  to  supply  the  wants  of  the  healthy  system,  conse- 
quently a  certain  amount  of  bread  is  permitted  to  most  patients,  and  cer- 


48  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

tainly  all  predisposed  to  phthisis  or  other  wasting  diseases  should  not  be 
placed  on  too  rigid  a  diet  even  for  a  short  time,  though  no  doubt  other 
patients  may  be  benefited  by  such  a  restriction.  The  usual  plan  adopted  in 
the  grape-cure  is  to  allow  as  much  of  the  ripe  fruit  as  the  patient  feels 
able  to  take,  beginning  with  about  a  pound  and  increasing  to  three,  five, 
seven,  and  sometimes  eight  pounds.  The  first  meal  is  taken  in  the  early 
morning,  and  eaten  in  the  vineN'ard  ;  not  so  the  others,  one  of  which 
would  correspond  with  our  breakfast,  another  with  evening  dinner,  and 
another  at  bedtime.  In  the  middle  of  the  day,  after  the  morning  walk,  a 
meal  of  bread  is  taken  and  water  to  drink.  Diet  of  this  kind  continued 
from  four  to  six  weeks  must  have  a  considerable  effect  and  cannot  be 
without  risk  for  tuberculous  constitutions.  At  first  the  grape-cure  sets  up 
purgation,  it  also  stimulates  the  kidneys  and  sometimes  proves  in  this 
way  too  debilitating.  It  might  therefore  be  considered  to  act  by  elimi- 
nation, bringing  about  destructive  changes.  No  doubt  this  is  so,  and  to 
this  is  due  the  good  results  in  lithiasis,  portal  congestion,  plethora,  etc. 
Here,  too,  is  the  risk  in  other  diseases,  but  inasmuch  as  some  of  these 
have  been  improved  it  would  seem  that  the  removal  of  the  waste  has 
brought  about  increased  repair,  and  thus  the  grape-cure  has  some  claim  to 
be  considered  an  indirect  promoter  of  construction. 

e.  Salts. — The  saline  substances  which  enter  into  the  tissues  and  the 
blood  are  in  a  certain  sense  nutrients,  and  one  or  other  of  them  has 
sometimes  been  spoken  of  as  food.  It  is  to  be  observed,  however,  that 
the  salts  are  only  one  class  of  the  necessary  ingredients  of  our  food,  and, 
though  exceedingly  important,  have  perhaps  the  least  power  of  sustain- 
ing life.  When  administered  in  extra  quantities  they  possess  other  ac- 
tions more  medicinal  than  nutritive,  and  will  therefore  be  considered  more 
conveniently  farther  on.  We  have  seen  how  they  promote  metamor- 
phoses and  perhaps  they  may  be  called  more  naturally  restorers  than"  pro- 
moters of  nutrition.  Such  a  distinction  may  be  drawn  between  nutrients 
proper  and  analeptics  or  restorers,  but  it  is  not  always  observed,  the 
words  being  frequently  interchanged.  We  have,  however,  as  a  matter  of 
convenience  placed  these  nutrients  together,  and  now  pass  on  to  ana- 
leptics. 

AxALEPTics. —  Cod-liver  oil  has  been  known  for  more  than  a  century^ 
Dr.  T.  Percival  having  been  acquainted  with  it  as  a  remedy  for  chronic 
rheumatism  about  1771.  He  sent  a  communication  to  the  Medical  Society, 
October  7,  1782,  with  a  letter  from  Dr.  Robert  Darbey,  giving  an  account 
of  its  accidental  introduction  some  ten  years  previously  to  the  Manches- 
ter Infirmary  [Lond.  Med.  Jour.,  1783).  A  number  of  articles  or  pam- 
phlets upon  its  use  were  published  before  it  was  recommended  by  Dr. 
Bardsley  in  1807,  who  tells  us  it  was  in  much  favor  in  I^ancashire  {Med. 
Rep.),  and  after  him  by  Dr.  Hughes  Bennett,  whose  work  appeared  in 
1841.     The   last   writer   demonstrated   its   great  value   in  phthisis,  since 


ALIMENTS    AS    REMEDIES NUTRIENTS    AND    ANALEPTICS.       49 

wliicJi  it  has  become  generally  employed  in  that  disease  as  well  as  in 
others  in  which  fatty  nutrients  and  analeptics  are  required.  In  1840,  in  the 
first  report  of  the  Hospital  for  Consumptives,  the  physicians  of  the  insti- 
tution, as  the  result  of  its  extended  use,  stated  that  "  no  other  conclusion 
can  be  drawn  than  that  cod-liver  oil  possesses  the  property  of  controlling 
the  symptoms  of  pulmonary  consumption,  if  not  of  arresting  the  disease 
to  a  greater  extent  than  any  other  agent  hitherto  tried."  In  1853  the 
Paris  Academy  of  Medicine  offered  a  prize  for  the  best  essay  on  the 
therapeutical  uses  of  cod-liver  oil.  The  prize  was  awarded  to  Dr.  E. 
Taufflieb,  but  Dr.  F.  Dubois  also  received  very  high  encomium.  Both 
essays  were  published,  and  as  may  be  expected  are  full  of  information. 
Dr.  de  Jongh  published  a  monograph  in  1853,  containing  many  analyses 
and  much  other  information.  From  this  time  interest  in  the  subject  has 
not  abated  and  numerous  communications  tending  to  confirm  our  esti- 
mate of  its  value  have  been  published.  The  oil  contains  about  seventy 
to  eighty  per  cent,  of  oleine  and  about  fifteen  to  twenty-five  per  cent,  of 
margarine,  with  certain  biliary  matters  derived  from  the  livers.  It  seems 
very  complex,  and  analyses  give  us  oleic,  palmitic,  and  stearic  acids  with 
glycerine,  acetic,  butyric,  phosphoric,  and  sulphuric  acids,  peculiar  sub- 
stances soluble  in  alcohol  or  ether,  traces  of  iodine  and  bromine,  phos- 
phorus, lime,  magnesia,  and  soda.  A  trace  of  iron  is  found,  but  this  is 
probably  accidental ;  it  has  been  thought  that  some  of  the  other  inorganic 
ingredients  may  also  be  accidental.  A  substance  named  gaduin  was  ex- 
tracted by  De  Jongh,  but  is  not  very  important.  By  a  reaction  with 
ammonia  in  distillation  propylamine  is  obtained.  The  biliary  principles 
are  felninic,  bili-felninic,  and  cholic  acids  and  bilifulvin.  The  iodine  has 
been  thought  to  account  for  some  of  the  properties,  but  it  is  very  small 
in  amount ;  De  Jongh  was  unable  to  find  more  than  the  four-hundredth 
part  of  a  grain  in  one  hundred  grains  of  oil.  The  sulphuric  acid  test 
by  no  means  proves  the  purity  of  the  specimen,  it  only  shows  the  pres- 
ence of  biliary  matter,  and  so  far  indicates  that  it  is  derived  from 
liver.  No  doubt  the  livers  of  various  species  of  gadus  are  continually 
employed,  and  that  other  fish  have  also  been  used,  either  alone  or  to 
mix  with  genuine  cod-liver  oil.  Perhaps  the  smell  and  the  taste  are  the 
best  indications  of  quality,  a  distinct  odor  of  ordinary  fish-oil  is  sus- 
picious. Great  improvement  has  taken  place  of  late  years  in  the  prepa- 
ration, and  the  best  specimens  are  not  nearly  so  disagreeable  to  the 
palate  as  formerly. 

All  that  we  have  stated  respecting  fatty  aliments  may  be  applied  to 
this  oil,  which  has  the  advantage  of  being  pre-eminently  easy  of  diges- 
tion. It  therefore  presents  us  with  an  easy  means  of  introducing  a  fatty 
nutrient  and  analeptic.  Moreover,  the  experiments  of  Naumann,  Manz, 
Simon,  Dugald  Campbell,  and  others,  tend  to  show  that  this  oil  facilitates 
absorption  and  also  oxidation,  and  general  experience  not  only  confirms 
4 


50  THERAPEUTICS    OF    THE    KESPIRATORY   PASSAGES. 

this,  but  shows  that  under  its  influence  the  blood  improves  in  quality.  It  is 
therefore  both  a  supporter  and  promoter  of  nutrition.  At  the  same  time 
it  does  not  disturb  an}'  of  the  functions  of  the  body,  unless  sometimes  di- 
gestion, for  in  excess  it  is  apt  to  give  rise  to  dyspepsia  and  perhaps  some 
diarrhoea.  We  should,  hovpever,  remember  that  the  same  may  be  said  of 
all  oils. 

There  can  be  no  question  that  as  animal  fats  are  so  m.uch  easier  of  di- 
gestion than  those  of  vegetable  origin,  so  this  fish  oil  is  more  digestible 
than  the  former.  Small  quantities  undoubtedly  promote  digestion,  as  we 
have  seen  other  fats  do.  Dr.  Pollock  found  one  or  two  ounces  a  day  given 
to  pigs,  one  ounce  to  sheep,  and  from  three  to  nine  ounces  to  bullocks 
helped  to  fatten  them,  but  larger  quantities  deranged  digestion. 

Many  attempts  have  been  made  to  trace  the  therapeutical  properties 
of  the  oil  to  one  or  other  of  its  constituents,  but  without  success,  and  un- 
less all  its  value  is  to  be  ascribed  to  the  peculiarly  digestible  oleine,  we 
must  consider  its  virtues  as  dependent  upon  this,  but  perhaps  reinforced 
by  other  ingredients.  A  peculiarly  digestible  fatty  food  should  be  able, 
upon  the  principles  we  have  laid  down,  to  accomplish  most  of  the  results 
we  observe  to  follow  a  course  of  the  oil.  Clearly,  then,  the  first  indication 
for  its  administration  is  defective  nutrition,  as  soon  as  some  degree  of 
emaciation  and  loss  of  strength,  with  perhaps  anaemia  is  observed,  this 
medicine  should  be  administered  and  will  often  suffice  to  restore  health, 
this  is  particularly  noticealjle  in  children  and  young  persons,  and  such  a 
condition  often  precedes  wasting  diseases,  which  thus  taken  in  time  may 
be  arrested.  In  scrofula,  besides  a  similar  form  of  debility,  we  get  more 
decided  evidences  of  malnutrition,  among  which  may  be  named  glandular 
affections,  as  well  as  a  tendency  to  frequent  catarrhal  attacks  of  the  res- 
piratory mucous  membrane,  and  even  pneumonia.  It  was  in  chronic 
rheumatism  that  the  oil  first  obtained  its  reputation,  and  in  some  of  these 
cases  it  will  be  successful — generally,  I  am  inclined  to  think,  in  patients  of 
a  strumous  disposition. 

But  the  disease  in  which  it  has  obtained  the  greatest  vogue  is  phthisis, 
in  which  it  is  consequentlj'  prescribed  almost  as  a  matter  of  routine  ;  and 
we  may  perhaps  be  permitted  to  speak  of  this  in  its  several  forms  as  one 
disease  without  entering  minutely  into  its  pathology,  for  it  cannot  be 
denied  that  in  all  forms,  whether  tubercular  or  fibroid,  scrofulous  or 
catarrhal,  the  most  important  indication  is  to  improve  nutrition.  In  the 
so-called  pre-tubercular  stage  we  have  no  more  valuable  remedy.  In  the 
advanced  stages  of  chronic  phthisis  it  has  less  chance  of  restoring  nutri- 
tion, though  it  sometimes  arrests  the  emaciation  and  produces  other  good 
effects,  such  as  relieving  the  cough,  retarding  the  progress  of  lung  mis- 
chief, and  so  prolonging  life.  Unfortunately  the  oil  is  sometimes  pre- 
scribed without  reference  to  the  state  of  the  digestive  organs,  and  some- 
times too  large  a  dose  is  given  to  begin  with.     It  is  not  well  to  give  it 


ALIMENTS    AS    EEilEDIES NUTRIENTS    AND    ANALEPTICS.       51 

during'  febrile  attacks,  and  therefore  it  is  a  good  plan  to  suspend  it  for  a 
time  when,  as  so  often  happens,  a  little  febrile  excitement  occurs.  It  will 
often  be  found  that  the  pulmonary  symptoms  subside  under  the  influence 
of  the  oil,  which  has  therefore  been  called  by  some  persons  an  expecto- 
rant, but  the  true  reason  of  the  improvement  is  rather  the  promotion  of 
nutrition.  Of  such  cardinal  importance  is  tliis,  that  it  is  generally  better 
to  put  aside  the  favorite  expectorants  and  narcotics,  which  have  often 
done  so  much  mischief,  and  to  attend  entirely  to  the  appetite,  and  direct 
all  our  efforts  to  the  maintenance  of  the  digestive  and  nutritive  functions. 
If  lung  symptoms  require  relief,  it  should  be  given  without  disturbing  the 
stomach  ;  inhalations  will  often  suffice  for  this,  and  are  among  our  most 
useful  remedies,  since  they  scarcely  ever  interfere,  with  nutrition.  When 
the  oil  cannot  be  digested,  attention  to  the  pi'in ice  vice  will  often  suffice 
to  produce  toleration  of  very  small  doses.  Alkalies,  bismuth,  bitters,  or 
even  iron  may  be  called  for,  but  not  so  often  as  is  generally  supposed,  for 
just  as  very  small  quantities  of  other  nutrients  will  produce  an  appetite, 
e.ff.,  a  teaspoonful  of  milk  or  beef-tea,  so  will  small  doses  of  cod-liver  oil  ; 
and  patients  who  at  first  feel  a  great  repugnance  for  the  remedy,  often 
come  to  take  it  without  dislike.  ,  Emulsions  are  more  easily  taken  by 
many  than  the  simple  oil,  and  often  more  easily  digested,  but  I  do  not 
recommend  them  to  be  made  with  potash.  Much  better  emulsions,  with- 
out the  drawback  of  the  alkali,  and  with  additional  nutritive  qualities,  are 
made  with  extract  of  malt ;  these,  however,  are  not  easily  prepared  on  a 
small  scale.  A  very  nutritious  emulsion  may  be  made  with  yolk  of  egg  and 
gum  arable,  to  which  sugar  may  also  be  added,  and  this  should  be  freshly 
prepared.  A  jelly  can  be  made  with  isinglass.  The  glyceritum-vitelli  may 
also  be  utilized  for  this  purpose.  It  is  common  to  flavor  such  emulsions, 
but  most  persons  will  prefer  them  more  simple,  and  to  me  the  well-made 
emulsions  with  extract  of  malt  seem  far  the  best,  and  if  taken  pure  and 
cold  may  almost  be  called  palatable,  tliough  if  mixed  with  warm  fluids,  as 
some  have  thoughtlessly  directed,  the  flavor  of  the  oil  is  intensified. 

When  the  oil  is  taken  pure,  attempts  are  made  to  disguise  it  by  the 
vehicle — the  various  bitter  and  aromatic  infusions  may  usually  be  taken 
for  this  purpose  ;  when  iron  and  quinine  are  given,  many  patients  prefer 
to  float  their  oil  on  their  mixture.  I  must,  however,  condemn  the  too 
common  recommendation  to  employ  whiskey  or  brandy  for  this  purpose; 
from  one  to  three  tablespoonfuls  of  these  spirits  is  often  recommended 
with  a  dose  of  the  oil,  a  method  of  using  alcohol  which  has  nothing  in  its 
favor.  If,  as  it  is  sometimes  said,  the  stimulus  promotes  the  digestion  of 
the  oil,  the  dose  for  such  a  purpose  ought  to  be  small,  and  ether  is  very 
much  better  than  alcohol.  Porter  and  ale  are  less  objectionable.  Chew- 
ing orange-  or  lemon-peel,  or  any  other  strong  flavoring  substance,  even  a 
pinch  of  salt,  are  innocent  methods  ;  or  Pavesi's  plan  of  deodorizing  with 
charcoal  and  flavoring  with  coffee  is  not  objectionable.     The  addition  of 


52  THERAPEUTICS    OF   THE    RESPIRATORY   PASSAGES. 

more  active  medicines,  such  as  phosphorus,  iodide  of  iron,  etc.,  whatever 
mav  be  said  as  to  the  utility  of  the  drugs,  renders  the  oil  generally  less 
easy  to  take.  It  is  said  that  the  pure  oleine  obtained  from  cod-liver  oil 
sometimes  agrees  when  the  oil  itself  cannot  be  tolerated. 

The  dose  must  bear  a  due  proportion  to  the  digestive  power.  Few 
people  can  digest  more  than  an  ounce  a  day,  and  the  experiments  already 
mentioned  show  that  the  limit  is  soon  reached.  It  is  usually  better  to 
begin  with  one  or  two  teaspoonfuls  once  a  day,  and  as  the  taste  becomes 
less  objectionable,  twice  a  day.  "With  delicate  stomachs  it  is  well  to 
begin  at  bedtime,  as  the  oil  is  digested  during  sleep,  and  thus  disagreeable 
eructations  are  not  perceived.  As  soon  as  it  is  easily  tolerated  the  best 
time  for  administration  would  seem  to  be  soon  after  meals,  as  that  would 
be  the  period  at  which  it  would  be  acted  upon  by  the  pancreatic  juice,  and 
pass  with  the  other  products  of  digestion  into  the  lacteals,  and  exercise 
such  influence  as  it  may  possess  in  the  process  of  sanguification.  When 
the  taste  is  not  at  all  objected  to,  it  may  sometimes  be  given  with  advan- 
tage between  the  meals,  especially  if  the  patient  can  take  other  kind  of 
nutrients,  say  milk,  egg,  etc.,  at  the  same  time,  and  really  stands  in  need 
of  additional  food.  It  is,  however,  unfortunately  too  often  found  that 
where  nutriment  is  so  much  needed  there  exists  the  greatest  repugnance 
toward  it,  and  then  the  best  way  is  to  endeavor  to  create  a  desire  for 
food  by  the  application  of  the  natural  stimulus — that  is  to  say,  by  giving 
it  in  minute  quantities.  In  such  cases  cod-liver  oil  in  very  small  doses 
will  sometimes  effect  the  purpose,  especially  in  the  form  of  malt-emulsion. 
"VVe  may  also  endeavor  to  assist  its  assimilation  by  the  addition  of  other 
substances  as  well  as  by  administering  medicines  to  improve  the  digestive 
organs.     The  most  important  of  these  is 

Ether. — We  have  seen  how  fat,  and  therefore  how  cod-liver  oil  is  di- 
gested— that  we  may  assist  the  process  by  emulsifying  it,  or  by  the  ad- 
ministration of  pancreatin  or  malt  extract.  Instead  of  supplying  artifi- 
cially the  digestive  fluid,  or  a  substitute  for  it,  can  we  stimulate  the  pan- 
creas and  duodenal  glands  to  increased  secretion  by  varying  the  diet  or  by 
the  administration  of  medicines  ?  How  to  attempt  this  by  diet  may  be 
easily  deduced  from  what  has  preceded.  With  regard  to  medicine,  ether 
deserves  considerable  attention.  The  object  of  its  administration  is  not 
to  disguise  the  oil  or  to  coax  the  stomach  into  receiving  it,  but  to  help 
its  digestion  ;  not,  indeed,  directly,  though  it  may  have  some  influence  in 
this  way,  but  by  a  direct  action  upon  the  pancreas.  Dr.  Balthazar  Fos- 
ter proposed  to  utilize  this  action  at  the  Oxford  meeting  of  the  British 
Medical  Association  in  1868,  and  he  has  employed  ether  in  conjunction 
with  oil  as  well  as  a  substitute  for  it.  He  was  led  to  this  practice  by  the 
experiments  of  Claude  Bernard,  who  found  that  when  ether  was  intro- 
duced into  the  stomach  a  considerable  flow  of  pancreatic  juice  soon  after- 
ward  followed.     Not  only  so,  but  there  was  always  a  degree  of  vascular 


ALIMENTS    AS    KEMEDIE8 NUTRIENTS    AND    ANALEPTICS.       53 

congestion  excited  in  the  digestive  tract,  such  as  is  caused  by  the  nor- 
mal excitement,  food.  The  pancreas  also  became  red  and  turgescent, 
as  it  does  during  digestion,  and  Bernard  accordingly  administered  ether 
in  order  to  increase  his  stock  of  pancreatic  juice.  For  he  tells  us  that  this 
fluid  issues  by  drops,  more  or  less  frequently,  from  the  tube  of  an  animal 
with  a  pancreatic  fistula  ;  but  when  ether  is  given  it  flows  much  more 
freely,  and  the  liquid  has  not  lost  any  of  its  characteristics.  Still  further, 
he  found  that  when  two  rabbits  were  killed  soon  after  they  had  received 
fat  and  ether  into  the  stomach,  one  of  them  having  had  the  pancreatic 
duct  tied,  its  lacteals  contained  only  transparent  lymph,  while  those  of 
the  other  were  filled  with  milky  fluid.  From  his  investigations  it  seems 
that  the  digestion  of  fats  should  be  increased  by  ether.  If  it  stimulates 
at  once  the  pancreas  and  glands  of  the  duodenum  to  pour  out  their  se- 
cretions more  freely,  these  must  necessarily  act  upon  the  cod-liver  oil 
presented  at  the  same  time,  and  if  it  not  only  emulsifies  within  the  sys- 
tem the  oil,  but  further  assists  its  absorption,  it  presents  us  with  a  most 
valuable  remedy.  Dr.  Foster  proceeded  to  put  this  conclusion  to  the 
test  of  clinical  experience,  and  he  found  the  results  highly  satisfactory. 
Under  the  influence  of  ether  he  often  observed  a  return  of  the  power  of 
taking  oil  and  fatty  food  which  had  been  previously  distasteful  or  had 
even  excited  sickness,  increased  appetite.  Improved  general  nutrition 
and  increase  of  weight,  diminution  of  cough  and  expectoration,  and  ces- 
sation of  night-sweats.  "  In  a  further  more  systematic  enquiry  on  50 
dispensary  cases,  in  which  only  those  were  considered  improved  in  whom 
physical  exploration  of  the  chest  and  decided  increase  in  weight  confirmed 
the  patient's  impressions,  we  find  that  of  IG  cases  in  the  first  stage  7  im- 
proved, 5  remained  stationary,  and  only  4  became  worse.  Of  19  cases  in 
the  second  stage  6  improved,  6  remained  stationary,  7  became  worse.  Of 
15  cases  in  the  third  stage  7  improved,  5  remained  stationary,  and  3  became 
worse.  The  increase  of  weight  in  the  first  stage  averaged  seven  and  one- 
half  pounds,  in  the  second  eight  pounds,  in  the  third  five  pounds.  Some 
of  the  cases  returned  to  their  ordinary  avocations  and  were  able  to  earn 
their  livelihood.  In  the  cases  that  did  best  the  povper  of  taking  fats, 
which  had  been  impaired,  returned,  and  the  gain  in  weight  was  maintained 
for  many  months.  It  may  be  added  that  in  all  the  cases  there  had  been 
marked  wasting  before  the  ether  was  given,  although  cod-liver  oil  had 
been  taken  in  at  least  half  the  cases. 

Dr.  E.  L.  Fox,  of  Clifton,  and  Dr.  Mapother,  of  Dublin,  confirmed  Dr. 
Foster's  opinion  of  the  advantages  of  etherized  oil,  which  is  further  sus- 
tained by  some  observations  of  Dr.  Ramskill  on  the  use  of  olive  oil  as  a 
remedy.  A  committee  of  the  New  York  Therapeutical  Society  (Dr. 
Andrew  H.  Smith,  chairman)  reported  (1879)  that  ether  often  enabled  the 
oil  to  be  taken  when  it  had  previously  disagreed,  but  they  had  no  cases 
bearing  on  the  ultimate  effect  of  the  ether  on  nutrition.     I  may  add  in 


54  THERAPEUTICS    OP    THE    RESPIRATORY    PASSAGES. 

conclusion,  that  etherized  oil  gave  satisfactory  results  at  the  North  Lon- 
don Consumption  Hospital  when  I  was  attached  to  it. 

Tlie  ether  may  be  given  in  the  oil,  aether  purus  /o7'tio)' being  employed, 
in  the  proportion  of  ten  minims  to  two  drachms  of  oil  to  begin  with, 
afterward  increasing  to  fifteen  and  twenty.  It  has  the  advantage  of 
masking  the  unpleasant  flavor  of  the  oil.  Some  patients  prefer  an  ether 
mixture  taken  before  or  after  the  oil,  or  it  may  be  floated  on  such  a  mixt- 
ure, from  fifteen  to  thirty  minims  or  more  of  spirits  of  ether  in  the 
necessary  quantity  of  water. 

The  general  effects  of  ether  somewhat  resemble  those  of  alcohol,  but 
are  much  more  evanescent.  The  liquid  is  rapidly  absorbed  and  as  rapidly 
eliminated,  for  the  most  part  through  the  lungs.  The  odor  is  perceived 
in  the  breath  very  quickly  after  a  dose  is  taken,  even  when  enclosed  in 
capsules.  Generally,  too,  a  portion  is  returned  by  eructation  almost  im- 
mediately. Even  when  injected  into  the  peritoneum  Majendie  found  the 
odor  rapidly  perceptible  in  the  breath  of  the  animal.  And  in  a  case  in 
which  half  an  ounce  had  been  taken  shortly  before  death,  at  the  post- 
mortem examination  the  odor  was  distinctly  perceived  on  opening  the 
skull.  Very  large  doses  produce  poisoning  somewhat  in  the  same  man- 
ner as  alcohol,  but  very  considerable  quantities  may  be  taken  when  the 
system  becomes  habituated  to  its  use.  Christison  mentions  a  man,  who 
for  several  years  got  through  sixteen  ounces  every  eight  or  ten  days. 
Bucquet,  the  chemist,  is  said  to  have  taken  a  pint  a  day  to  assuage  the 
agonies  of  schirrus  of  the  colon,  of  which  he  died. 

In  small  doses  its  exciting  effect  is  perceived,  increasing  the  power 
and  the  frequency  of  the  heart's  beat,  bringing  on  flushing  of  the  face, 
warmth  of  the  surface,  sometimes  perspiration  ;  there  is  also  some  mental 
excitement,  which  soon  subsides  into  calmness,  or  even  torpor.  S'  tran- 
sient, however,  is  the  effect  and  so  rapid  the  elimination  by  the  lungs, 
that  generally  a  full  medicinal  dose  will  have  disappeared  in  an  hour, 
from  which  it  may  be  argued  that  moderate  doses  at  short  intervals  are 
most  likely  to  be  of  service.  It  is  often  given  in  spasmodic  and  nervous 
diseases  where  there  is  a  good  deal  of  pain  or  distress  without  inflamma- 
tion, e.g.,  in  colic,  in  gastralgia,  flatulency,  nervous  palpitation,  etc. 
With  regard  to  respiratory  diseases  it  is  recommended  in  spasmodic 
asthma,  pertussis,  various  forms  of  dyspnoea,  some  forms  of  chronic 
catarrh,  and  in  phthisis.  With  regard  to  this  class  of  diseases  it  will  be 
observed  that  it  is  chiefly  as  an  antispasmodic  that  it  is  employed.  And 
it  often  affords  rapid  relief,  if  only  temporary,  in  all  forms  of  spasmodic 
neurosis.  In  catarrhal  cases  it  is  to  be  tried  with  caution,  and  often  in- 
halation with  steam  will  be  the  best  mode  of  administering  it.  It  may 
be  advantageously  combined  with  conium  for  this  purpose.  An  ethereal 
tincture  has  often  been  employed,  but  a  much  more  effectual  remedy  is 
the  vapor-conii,  with  the  addition  of  ether. 


ALIMENTS    AS    REMEDIES NUTRIENTS    AND    ANALEPTICS.       00 

The  ordinary  dose  of  ether  is  from  twenty  to  sixty  minims.  The 
spirit  is  more  convenient,  as  it  mixes  freely  witli  water,  thirty  to  one  hun- 
dred and  twenty  minims  may  be  given.  The  compound  spirit — Hoff- 
mann's anodyne — contains  some  ethereal  oil  and  seems  more  anti-spas- 
modic. Capsules  or  perles  of  Dr.  Clertan  are  convenient,  especially 
when  the  taste  is  objected  to,  but  they  must  be  washed  down  quickly 
lest  they  burst  en  route  and  cause  local  irritation. 


ciiAPTEii  vm. 

IKON. 

This  metal  is  found  in  the  tissues,  but  to  a  much  greater  extent  in 
the  blood,  of  wliich  it  is  one  of  the  most  important  constituents.  Some 
have  denied  that  medicinal  doses  are  absorbed  ;  but  it  must  be  derived 
from  the  food,  is  in  fact  a  necessary  constituent  of  our  diet,  and  when 
from  any  cause  we  have  reason  to  believe  it  is  deficient  in  quantity,  it 
seems  rational  to  give  it  as  we  should  other  proximate  principals.  More- 
over, many  experiments  have  shown  that  after  its  administration  larger 
quantities  have  been  found  in  the  blood  as  well  as  in  the  secretions,  be- 
sides which  absorption  has  been  proved  to  take  place  from  the  cellular 
tissue.  Those  salts  which  are  insoluble  in  water  may  easily  be  dissolved 
or  acted  upon  by  the  gastric  juice.  The  pure  metal,  minutely  divided 
as  in  reduced  iron,  is  perhaps  first  oxidized  by  the  help  of  water,  hydro- 
gen being  set  free,  and  this  accounts  for  disagreeable  eructations  of  sul- 
phuretted hydrogen  occurring  when  any  sulphur  is  present  and  this  prep- 
aration is  employed.  Formerly  it  was  said  that  all  protosalts  quickly 
became  persalts  in  the  stomach,  but  though  such  a  change  rapidly  occurs 
outside  the  body  it  is  not  necessarily  so  within.  In  fact,  some  experi- 
ments seem  to  indicate  that  the  reverse  change  may  occur.  Stenhouse 
found  that  persalts  were  readily  reduced  by  organic  substances,  and  Claude 
Bernard,  after  injecting  into  the  jugular  vein  a  persalt,  found  only  a 
protosalt  in  the  renal  secretion.  If  the  persalts  obtain  access  to  the  sys- 
tem it  seems  probable  that  they  can  only  exist  as  such  a  very  short  time. 
As  to  the  salts  of  the  organic  acids,  it  seems  they  may  be  absorbed  at 
once  when  the  acid  is  oxidized  and  the  nascent  metal  left  free  to  form 
other  combinations,  a  carbonate  being,  according  to  Rabuteau,  most 
likely  formed  in  the  same  way  that  similar  salts  of  the  alkalies  are  de- 
composed and  their  carbonates  formed.  Protoxide  and  carbonate  would 
be  easily  converted  into  protochloride  by  the  gastric  juice.  So,  per- 
haps, would  sesquioxide  passing  first  through  the  state  of  perchloride, 
and  it  should  be  observed  that  protochloride  does  not  precipitate  al- 
bumen and  could  therefore  be  absorbed.  Even  the  salts  of  the  min- 
eral acids,  if  given  sufficiently  diluted,  need  not  necessarily  coagulate 
albumen    or    act  as    astringents  on    the   mucous  membrane,  and    might 


IKON.  07 

therefore  be  absorbed,  but  we  certainly  find  that  these  preparations 
are  more  apt  to  interfere  with  digestion,  wliich  seems  to  show  that  ordi- 
nary medicinal  doses  are  astringent.  Probably  iron  is  generally  absorbed 
as  an  albuminate,  and  it  is  certainly  for  the  most  part  eliminated  in  albu- 
minous secretions.  To  this  last  fact  Gubler  points  as  explanatory  of  the 
remote  astringent  action  of  iron,  supposing  the  metal  to  be  separated  by 
the  secreting  surface  from  the  albumen  and  then  to  exercise  its  natural 
astringency.  A  large  proportion  of  iron  is  eliminated  from  the  bile,  and 
some  have  thought,  therefore,  that  all,  or  nearly  all,  passes  to  the  portal 
circulation  without  entering  the  general  circulation.  But  it  has  also  been 
supposed  that  much  of  the  iron  in  the  bile  is  derived  from  effete  blood- 
corpuscles  being  broken  up  in  the  liver.  Still  we  must  admit  some  may 
be  absorbed  and  eliminated  through  the  bile  or  the  intestinal  secretion, 
some  may  be  taken  up  with  the  fats  and  products  of  late  digestion,  while 
yet  another  portion  may  pass  on  undigested.  These  results  may  vary 
with  the  preparation,  the  dose,  the  degree  of  dilution,  the  time  of  admin- 
istration, and  the  state  of  the  digestive  organs,  and  most  of  these  deter- 
mining conditions  are  under  the  control  of  the  physician,  and  it  is  desir- 
able so  to  regulate  them  as  to  obtain  all  the  benefits  of  the  remedy 
without  any  inconvenience.  We  have  said  that  iron  is  in  the  tissues  as 
well  as  the  blood,  and  this  is  why,  as  an  essential  ingredient,  we  regard  it 
as  one  of  the  nutrients  in  the  sense  in  which  we  have  already  discussed 
them.  In  the  blood  it  is  in  combination  with  the  h.iemoglobin,  forming 
about  OA'Z  per  cent.,  its  chief  use  being  as  a  purveyor  of  oxygen  ;  in  the 
lungs  the  haemoglobin  takes  up  oxygen  and  thereby  becomes  oxy- 
hfemoglobin,  the  result  of  this  being  that  the  purple  venous  blood 
becomes  the  scarlet  arterial.  This  is  carried  in  the  vessels  to  the  tissues, 
to  which  it  gives  up  its  oxygen  and  so  is  reduced  again.  Thus  it  is  by 
virtue  of  their  ha?moglobin  that  the  red  corpuscles  are  carriers  of  oxygen 
to  the  tissues,  and  it  is  curious  to  observe  how  easily  the  oxygen  is  asso- 
ciated and  dissociated  without  disturbing  much  their  molecular  state. 
Other  gases  may  also  be  taken  up,  e.g.,  carbon-monoxide,  but  this  is  less 
easily  dissociated,  hence  its  poisonous  qualities,  for  this  gas  is  useless  in 
respiration  and  the  person  is  asphyxiated  though  the  blood  is  found  red. 
The  iron  is  in  intimate  union  with  the  red  corpuscles,  and  this  union 
would  seem  to  be  not  merely  chemical.  Some  have  conjectured  that  it 
may  be  present  in  the  metallic  state  ;  but  Liebig,  Mialhe,  and  others  con- 
sider that  it  is  present  as  a  peroxide,  which  in  contact  with  moist  tissues 
might  become  protocarbonate,  and  this  on  exposure  to  oxygen  in  the 
lungs  would  give  up  its  carbonic  acid  and  reassume  its  former  state. 
But  there  are  difficulties  in  accepting  this  theory,  which  would  account 
for  the  properties  of  the  corpuscles  by  the  purely  chemical  action  of  the 
contained  iron.  We  must  recognize,  however,  that  these  corpuscles  are 
the  purveyors  of  oxygen  to  the  tissues,  and  that  the  iron  is  essential  to 


58  THERAPEUTICS    OF    THE    RESPIRATORY   PASSAGES. 

the  hreinatin,  and  no  doubt  concerned  in  its  function.  Iron  is  also  pres- 
ent in  niyochrome.  Now,  if  the  iron  brings  the  oxygen  to  the  tissue  and 
also  takes  some  part  in  the  oxidation  of  tissue,  it  may  be  argued  that  this 
is  a  disintegrating  process,  and  therefore  that  the  metal  should  not  be 
considered  as  a  promoter  of  construction.  We  have,  however,  already 
shown  that  it  is  an  essential  ingredient  of  the  body,  that  it  is  usually 
supplied  in  the  food  and  eliminated  in  the  secretions.  It  is  therefore 
entitled  to  be  considered,  among  the  proximate  principles  of  aliment, 
the  most  important  in  its  class,  perhaps;  moreover,  deficiency  of  its  supply 
is  followed  by  characteristic  symptoms,  which  are  removed  by  its  ad- 
ministration, apart  from  which  clinical  observation  has  universally  pro- 
nounced that  it  possesses  tonic  properties.  Further,  even  if  it  should  be 
shown  to  hasten  destructive  tissue  changes,  we  have  seen  that  this  pro- 
cess within  certain  limits  indirectly  promotes  construction;  and,  finally, 
it  may  be  said  that  the  presentation  of  tlie  oxygen  to  the  tissue,  though 
it  stimulates  oxidation,  being  a  necessary  constant  condition  of  nutrition, 
may  be  regarded  much  in  the  same  light  as  the  presentation  of  the  other 
nutrient  principles,  v,-hich,  as  we  have  seen,  stiaiulates  construction. 

If  the  iron  increase  oxidation  it  should  raise  the  temperature,  as 
it  should  also  if  it  excited  more  active  constructive  changes.  Pokrowsky 
believed  that  he  did  detect  a  rise  in  the  temperature  after  the  exhibition 
of  iron,  and  that  in  some  cases  within  five  hours  after  the  first  dose,  so 
that  it  could  not  be  due  to  an  increase  in  the  number  of  the  red  corpus- 
cles, as  that  could  only  take  place  slowly;  the  elimination  of  urea  was  at 
the  same  time  increased.  It  is  unfortunate  that  the  iodide  of  iron  was 
employed,  as  the  iodine  could  not  be  without  its  effect.  Picard  has 
shown  that  a  definite  constant  relation  exists  between  the  amount  of  iron 
in  the  blood  and  the  amount  of  oxygen.  Recent  investigations  by  Ra- 
buteau  tend  to  show  that  iron  increases  oxidation,  and  many  regard  it 
as  the  active  agent  in  the  red  corpuscles  for  condensing  oxygen  into 
ozone,  though  they  are  not  prepared  to  admit,  with  Sasse,  that  the  metal 
can  supply  the  place  of  red  corpuscles  as  an  ozonizing  agent ;  if  it  could, 
we  should  be  able  to  accomplish  more  by  its  use. 

Somewhat  contradictory  results  have  been  reported  as  to  the  effect  of 
iron  on  the  pulse.  It  is  mostly  believed  to  give  tone  to  the  circulation  and 
to  make  the  pulse  fuller  and  more  forcible,  though  often  slower;  but  others 
state  that  it  increases  the  frequency  of  the  pulse,  and  it  is  a  common 
observation  that  it  appears  to  increase  congestions.  So  far  as  it  favors 
oxidation,  it  tends  to  increase  the  production  of  heat  and  to  quicken  the 
pulse  ;  but  this  last  symptom  may  be  more  than  neutralized  at  a  later 
stage  by  the  increased  strength  which  follows  improved  sanguification. 
In  purpura  and  other  conditions  it  certainly  seems  to  quiet  the  pulse 
unless  it  irritates  the  stomach.  It  appears  to  give  tone  to  the  capillaries 
and  to  stimulate  their   contraction,  to  which  may  be   partly  ascribed  its 


IKON".  59 

power  over  hemorrhages  and  discharges.  As  to  its  other  effects  on  the 
circulation,  the  improvement  in  the  tint  of  anaemic  persons  under  a  course 
of  iron  is  sure  to  attract  attention.  It  is  even  said  to  induce  plethora, 
but  perhaps  this  is  going  too  far,  or  may  only  be  a  forcible  way  of  saying 
that  it  is  contra-indicated  in  individuals  displaying  a  plethoric  tendency. 

The  hrematinic  effects  of  iron  may  be  measured  by  clinical  observa- 
tion, but  of  late  years  we  have  been  able  to  adopt  Malassez's  method  of 
counting  the  blood-corpuscles,  and  lately  Dr.  Amory  has  succeeded  in 
projecting  upon  a  screen  a  magnified  image  of  the  slide  employed  in  this 
method  for  the  purpose  of  demonstration.  It  has  been  shown  again  and 
again  that  the  corpuscles,  when  diminished  in  number,  rapidly  increased, 
as  determined  by  the  hcemacytometer,  under  the  intiuence  of  preparations 
of  iron.  It  is  true  that,  according  to  Ilayem,  the  number  was  not  always 
increased,  and  Claude  Bernard  found  that  the  corpuscles  were  not  in- 
variably deficient  in  the  blood  of  chlorotic  patients.  On  the  other  hand, 
Hayem  found  the  globules  improved  in  quality,  that  is  in  size,  shape,  and 
color,  under  the  influence  of  iron  in  cases  in  which  there  was  no  deficiency 
in  their  number.  In  anaemia  and  in  chlorosis  of  moderate  degree,  when 
the  number  was  not  markedly  deficient,  he  found  alterations  in  size  and 
shape  as  well  as  in  coloring  power,  which  last  was  sometimes  diminished 
to  the  extent  of  half — that  is  to  say,  a  given  quantity  only  showed  half 
the  depth  of  tinge  that  it  should  have  done.  After  a  course  of  iron  the 
corpuscles  from  these  patients  recovered  their  natural  coloring  power  as 
well  as  their  ordinary  size  and  shape.  Many  observers  have  found  large 
increase  in  number,  and  thus  corroborated  the  views  which  had  been  en- 
tertained, and  which  were  supported  by  chemical  analyses,  such  as  those 
of  Simon,  who  found  the  globulin  and  htematin  doubled  and  trebled  in 
weight.  It  would  seem  as  if  the  presence  of  iron  in  abundance  excited 
a  more  active  manufacture  of  corpuscles,  just  as  other  nutrient  principles 
provoke  more  energetic  construction  of  the  tissues  into  which  they  prin- 
cipally enter  ;  moreover,  the  blood-glands  are  perhaps  stimulated  by  the 
iron,  and  then  again,  when  the  corpuscles  have  been  deficient,  their  in- 
crease promotes  other  functions,  which  in  their  turn  depend  on  the  circu- 
lation of  healthy  blood.  Thus,  when  given  in  appropriate  cases,  not  only 
is  the  blood-forming  process  rendered  more  active,  but  digestion  is  im- 
proved, nervous  tone  imparted,  and  all  the  functions  rendered  more 
healthy. 

In  order  to  secure  the  hjematinic  effects  of  iron,  only  small  doses  are 
required,  provided  the  medicine  be  given  in  a  form  which  can  be  easily 
absorbed.  The  total  amount  present  in  the  blood  of  a  healthy  adult  is 
estimated  at  from  thirty-seven  to  forty-seven  grains,  and  the  deficiency 
is  believed  scarcely  ever  to  exceed  fifteen  or  twenty  grains,  even  in  severe 
cases  of  anf^mia.  It  has  further  been  estimated  that  in  health  about  a 
grain  a  day  is  usually  taken  up  and  eliminated,  but  in  disease  as  much 


60  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

as  four  or  five  times  this  quantity  has  been  assimilated  during  a  short 
period.  The  blood  will  not  take  up  more  iron,  nor  form  more  hfeniatin, 
than  the  normal  amount,  so  that  we  cannot  increase  the  richness  of  the 
blood  beyond  the  standard  of  health.  But  it  does  not  follow  that  un- 
limited quantities  may  be  given.  On  the  contrary,  large  doses  are  likely 
to  derange  digestion,  and  so  defeat  the  object  with  which  they  are  given. 
They  also  impede  secretion,  thereby  hindering  absorption  and  constipat- 
ing the  bowels.  Something  of  course  depends  on  the  form  in  wliich  the 
iron  is  presented,  the  preparation,  the  dose,  and  the  degree  of  dilution; 
something,  too,  on  the  state  of  the  stomach.  The  unabsorbed  portion 
passes  through  the  alimentary  canal,  becoming  for  the  most  part  a  sul- 
phide, small  quantities  of  which  tend  to  constipate  by  checking  secretion, 
though  larger  quantities  may  irritate,  and  so  produce  diarrhoea.  Iron  is 
also  eliminated  by  the  kidneys  and  liver,  the  rate  of  removal  being  in 
accordance  with  the  rate  of  absorption,  this  taking  place  more  easily 
when  the  dose  is  small  and  largely  diluted  and  the  preparation  employed 
least  astringent. 

Diminution  of  iron  in  the  sj^stem — anrcmia — may  be  brought  about 
by  a  deficiency  of  the  metals  in  the  food,  by  an  impairment  in  the  power 
of  absorbing  it,  or  by  some  hindrance  to  the  process  of  sanguification. 
These  causes  resolve  themselves  into  a  diminution  of  supply.  On  the 
other  hand,  the  same  results  may  be  brought  about  by  increase  in  the 
waste  ;  the  loss  by  elimination  may  be  in  excess,  or  all  the  constituents 
of  the  blood,  including  the  iron,  may  be  removed,  as  in  the  case  of  hem- 
orrhages. When  the  cause  is  not  persistent,  health  returns  under  the 
influence  of  good  food,  but  much  more  quickly  when  some  iron  salt  is 
also  given,  and  the  rate  of  improvement  is  easily  measured  by  counting 
the  corpuscles.  In  the  anaemia  of  convalescence,  or  after  loss  of  blood, 
or  in  exhausting  discharges,  the  effect  is  very  manifest,  and  the  more 
acute  and  tlie  more  direct  the  antemia  the  more  rapid  and  the  more 
marked  is  the  improvement.  These  effects  have,  however,  been  denied. 
Trasbot  does  not  admit  the  hjematinic  power  of  iron,  and  so  able  an  ob- 
server as  Dujardin-Beaumetz  speaks  of  its  use  as  a  therapeutical  illusion. 
They  stand,  however,  almost  alone  in  this  opposition  to  the  general  ex- 
perience of  the  profession,  supported  as  it  is  by  both  theory  and  experi- 
ment in  all  cases  of  direct  anremia,  whether  from  loss  of  blood,  excessive 
secretion,  acute  disease,  interfering  with  food  supply  and  bringing  about 
as  it  were  a  degree  of  starvation,  so  that  the  blood  is  deficient  in  iron  as 
well  as  probably  albuminous  constituents.  There  is  no  doubt  that  the 
restorative  influence  of  good  food  may  be  greatly  increased  by  the  admin- 
istration of  iron,  provided  it  is  so  given  and  in  such  quantities  as  not  to 
interfere  with  digestion.  In  order  to  prevent  relapse  it  is  very  desirable 
to  continue  the  remedy  for  some  time  after  recovery. 

Idiopathic    or  pernicious  anaemia,  as   it    has   been   called,  is  not    so 


IRON".  61 

amenable  to  iron,  perhaps  from  there  being  some  difBcuIty  in  assimila- 
tion, though  some  cases  have  been  benefited  by  the  hypodermic  injection 
of  dialyzed  iron.  But  it  may  be  said  that  there  is  a  further  profound  in- 
terference with  nutrition  than  the  intense  antemia  of  these  cases. 

In  chlorosis  similar  statements  may  be  made  to  those  referred  to  in 
anaemia.  Here,  also,  diet,  fresh  air,  exercise,  and  other  hygienic  influ- 
ences are  of  the  first  importance  and  may  sometimes  effect  a  cure,  but 
this  may  always  be  hastened,  and  sometimes  can  only  be  obtained,  by 
adding  a  course  of  iron.  Very  often,  too,  aperients  are  particularly  de- 
sirable ;  hence,  perhaps,  the  popularity  of  formuke  combining  these  with 
iron,  as  in  pilula  aloes  et  ferri.  Sometimes,  however,  astringent  prepara- 
tions are  required,  but  in  almost  all  cases  attention  to  the  primce  vice  is 
of  the  utmost  importance,  and  soothing,  stimulating,  or  other  remedies 
may  be  resorted  to  according  to  circumstances,  with  a  view  of  promoting 
digestion  and  the  assimilation  of  the  iron.  In  numerous  cases  fatty  food 
is  also  of  importance,  and  fresh  air  and  exercise  should  never  be  over- 
looked.    Da  Costa  has  obtained  good  results  from  hypodermic  injection. 

Speaking  of  the  difficulty  of  securing  assimilation  leads  us  to  a  re- 
mark on  the  effect  of  the  metal  on  digestion.  Too  large  a  dose  impedes 
the  process  and  causes  irritation,  and  these  same  eff^ects  are  often  pro- 
duced by  the  stronger  preparations,  when  the  weaker  ones  are  easily 
taken.  Further,  when  no  intolerance  appears  and  the  remedy  even  seems 
to  promote  digestion — which  it  perhaps  does  by  acting  as  a  stimulus  to 
the  gastric  mucous  membrane — after  a  time,  perhaps,  it  may  disagree, 
bringing-  on  a  sense  of  weight  and  irritation,  or  even  more  pronounced 
symptoms  of  indigestion.  Perhaps  this  may  arise  from  over-stimulation 
of  the  gastric  glands,  or,  on  the  other  hand,  from  a  diminished  secretion 
brought  about  by  the  astringent  properties  of  the  medicine.  It  sometimes 
occurs  from  the  administration  at  improper  times.  Querance  found  in  his 
experiments  on  dogs  with  a  gastric  fistula  that  iron  improved  the  peptones 
when  given  with  food,  though  it  did  not  increase  the  proportion  of  pepsin 
nor  diminish  the  time  of  digestion.  The  dogs  gained  flesh  when  thus 
given,  but  when  administered  without  food,  especially  in  metallic  form, 
the  iron  did  not  cause  sufficient  secretion  to  bring  about  its  solution,  and 
therefore  remained  in  the  stomach  undissolved  and  caused  irritation  of 
the  stomach  and  bowels.  To  prevent  disagreeable  symptoms,  then,  the 
medicine  should  be  given  with  the  food,  the  lighter  preparations  so  far 
as  suitable  to  the  case  should  be  selected.  Combination  with  other  medi- 
cines may  often  be  desirable,  and  in  all  cases  absence  of  gastric  irrita- 
tion, biliousness  or  pyrexia  is  desirable.  It  may  be  added  that  in  certain 
forms  of  atonic  dyspepsia  with  general  debility,  and  especially  any  ten- 
dency to  ansemia,  iron  preparations  are  not  only  tolerated  but  are  most 
beneficial. 

As  regards  secretion  the  effect  as  already  shown  is  astringent.     In 


62  THEEAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

some  instances,  on  the  other  hand,  an  opposite  effect  is  spoken  of,  though 
very  often  that  can  only  be  indirect  that  is  the  consequence  of  the  re- 
storative action. 

In  hemorrhages  the  action  is  both  local  and  general.  As  a  styptic  in 
bleeding  from  the  tonsils  after  operation,  as  well  as  in  epistaxis  and  other 
accidental  hemorrhages,  the  perchloride  or  the  subsulphate,  as  in  ^Monsel's 
solution,  may  be  safely  employed.  In  hsemoptysis  a  spray  is  often  very 
effectual  and  either  perchloride  or  the  ordinary  sulphate  may  be  used. 
It  has  been  thought  that  this  would  lead,  by  coagulating  the  blood,  to 
fresh  congestion,  but  chemical  experience  has  not  found  this  to  be  so. 
Caution  is  necessary  in  administering  iron  internally  in  phthisis  with  a 
tendency  to  hjemoptysis,  but  there  is  little  objection  to  its  use  as  a  spray. 

In  diphtheria  the  local  and  general  use  of  perchloride  has  become  as 
popular  as  in  erysipelas.  Here,  too,  the  spray  is  generally  better  than 
the  ruder  swab,  which  is  often  too  roughly  applied.  Internally  the 
tincture  or  liquor  has  been  employed  even  more  extensively,  and  perhaps 
with  better  effect  than  locally.  It  was  used  in  the  earlier  epidemics  by 
Jodin  and  Aubrun,  in  France,  and  by  Dr.  Godfrey  and  Dr.  Heslop  in 
England,  in  1857  and  1858.  It  has  maintained  its  position  as  a  valuable 
agent  up  to  the  present  time,  many  observers  being  convinced  that  it  is 
a  direct  restorative  and  exercises  a  remarkable  influence  in  preventing 
blood-poisoning.  Isnard  believed  that  it  might  prevent  exudation,  just 
as  it  is  admitted  to  restrain  hemorrhage,  and  that  by  rendering  the  blood 
more  plastic  it  diminished  the  liability  to  the  blood-poisoning,  and  his 
idea  seems  to  have  become  popular.  To  attain  this  object  it  should  be 
begun  early  and  given  at  frequent  intervals.  Aubrun  gave  a  dose  every 
five,  ten,  or  fifteen  minutes,  day  and  night,  for  the  first  three  days  after 
the  invasion,  after  which  he  gave  it  less  frequently,  as  he  believed  that 
by  that  time  the  membrane  would  become  detached  or  cease  to  be  formed. 
Others  urge  frequent  doses  and  some  large  doses,  under  the  idea  of  quick- 
ly acting  on  the  blood.  Jenner  considers  it  beneficial  only  in  certain 
cases  which  seem  suitable  for  it,  and  Dr.  George  Johnson  regards  it  as 
the  most  successful  of  all  medicine.  The  evidence  in  favor  of  its  value 
is  certainly  great,  but  too  much  reliance  must  not  be  placed  on  this  or 
any  other  medicine.  The  majority  of  cases  seem  very  suitable  for  it, 
and  it  should  be  given  with  no  sparing  hand,  but  local  applications  or 
sprays  of  this  or  other  medicines  should  not  be  neglected,  and  above  all 
attention  should  be  given  to  maintain  nutrition,  disinfection,  or  ventilation. 
The  existence  of  albuminuria  and  even  the  appearance  of  blood-  or  tube- 
casts  in  the  urine  need  not  prevent  the  use  of  the  remedy,  though  in 
such  cases  it  is  perhaps  as  well  to  combine  it  with  nitric  or  hydrochloric 
acid  or  such  other  remedies  as  may  be  indicated.  We  may  here  recall 
an  expression  of  Sir  .Tames  Simpson's  when  recommending  the  tincture 
in  surgical  fever  :  he  termed  it  "  a  renal  purgative." 


lEOisr.  63 

In  scarlet  fever  similar  favorable  results  have  been  obtained  by  the 
use  of  the  perchloride  internally  as  well  as  in  the  form  of  sjjrays  ;  and 
the  same  may  be  said  as  to  the  angina  of  other  exanthemata. 

In  bronchial  affections  iron  is  chiefly  useful  during  convalescence, 
but  it  sometimes  is  also  benefical  in  chronic  bronchitis  attended  with 
profuse  expectoration  ;  it  also  restrains  the  amount  of  secretion  in  bron- 
chorrhoea  and  somewhat  modifies  its  character.  Perhaps  this  is  by  an 
astringent  effect  on  the  mucous  membrane,  or  it  may  be  merely  by  im- 
proving the  state  of  the  blood  or  the  general  health,  though  it  has  some- 
times been  pronounced  to  be  an  alterative  on  the  respiratory  tract.  Per- 
haps it  is  more  of  a  tonic  to  this  membrane,  acting  directly  on  the  capil- 
laries, which  would  account  for  the  fact  that  it  is  often  beneficial  in  em- 
physema. Either  the  phosphates  or  the  more  astringent  preparations  are 
most  frequently  indicated  in  affections  of  the  air-passages. 

In  phthisis  considerable  differences  of  opinion  have  prevailed  as  to 
the  use  of  chalybeates.  Trousseau  and  others  have  expressed  a  fear  lest 
iron  should  aggravate  the  disease,  particularly  in  its  early  stages,  and  cer- 
tainly when  there  is  considerable  pyrexia  or  any  pulmonary  congestion 
or  a  tendency  to  haemoptysis  it  may  be  well  to  postpone  this  remedy  ; 
but  when  there  is  no  marked  febrile  I'eaction,  especially  if  there  be  any 
disposition  to  anfemia,  a  short  course  of  a  light  preparation  may  be  of 
great  service,  especially  in  conjunction  with  cod-liv^er  oil  or  a  consider- 
able amount  of  fatty  food.  Iodide  of  iron  has  been  largely  used  in 
such  cases,  but  it  must  be  remembered  that  this  preparation  should  be 
considered  as  one  of  iodine,  rather  than  of  iron.  In  the  later  stages 
of  this  disease  the  good  effects  are  much  more  manifest  and  the  stronger 
astringent  preparations  may  be  employed  to  restrain  expectoration, 
night-sweats,  diarrhoea,  and  even  the  passive  hsemoptysis  which  some- 
times recurs.  Under  the  influence  of  the  tonic  the  appetite  ofen  im- 
proves, more  food  is  taken,  and  apparently  more  assimilated.  The  taste 
for  fatty  food  returns  and  the  emaciation  is  arrested.  Care  should  be 
taken  to  select  a  preparation  which  will  not  disagree  with  the  stomach  ; 
the  lighter  ones  are  almost  always  well  borne,  but  when  night-sweats  or 
other  indications  for  an  astringent  are  present,  the  perchloride  is  the 
most  generally  useful. 


CHAPTEE  IX. 
PHOSPHOEUS  AND   ITS    COMPOUNDS. 

Some  combination  of  phosphorus  is  found  in  all  the  tissues  and  in 
all  the  fluids  of  the  body.  It  lias  therefore  been  said  to  be  as  important 
an  element  of  organic  structures  as  nitrogen  or  carbon,  and  as  absolutely 
essential  for  the  growth  of  a  penicilium  as  a  man.  Experience  shows 
its  importance  to  vegetable  life — bacteria  and  fungi  require  earthy  phos- 
phates and  their  value  to  corn-crops  is  well  known.  Phosphorus  is  an 
important  constituent  of  lecithin  (C^^H^^^NPOg,  from  XcKt^os,  yolk  of  egg), 
in  which  it  was  first  found,  and  it  used  to  be  called  phosphorized  fat, 
because  one  product  of  its  decomposition  is  phospho-glyceric  acid  (C^ 
HgPOg).  It  is  most  abundant  in  the  solids,  on  account  of  the  large 
amount  of  tissue  phosphates  in  the  skeleton,  but  it  is  also  a  very  im- 
portant constituent  of  the  fluids.  It  enters  tlie  body  in  the  food  and  is 
removed  in  the  excretions  as  phosphates. 

As  the  salts  have  been  long  employed  in  medicine  it  will  be  conve- 
nient to  consider  them  first. 

Calcium,  2yhosphate  (as  well  as  the  magnesian  salt)  is  considered  not 
only  to  impart  solidity  to  the  bones  but  to  be  an  important  agent  in  the 
consolidation  of  the  other  tissues.  In  bone  it  is  associated  with  other 
salts  but  forms  five  or  six  times  as  much  as  all  the  other  mineral  ingredi- 
ents combined,  no  less  than  fifty-seven  or  fifty-eight  per  cent,  of  bone  be- 
ing lime  phosphate.  It  is  not  deposited  as  a  mere  granular  powder, 
neither  does  it  form  such  a  chemical  combination  as  to  lose  its  identity. 
It  unites  more  like  a  salt  in  a  saline  solution,  or  the  pigment  in  colored 
glass.  Of  the  fluids  it  is  present  in  largest  amount  in  the  milk,  ob- 
viously on  account  of  its  necessity  for  the  growth  of  the  infant's  bones. 
In  the  blood-plasma  it  is  held  in  solution  apparently  by  albuminous  in- 
gredients, for  Fokker  found  that  earth}'  phosphates  united  with  white 
of  egg  and  became  soluble  in  some  proportion  ;  and  this  explains  how 
blood  and  milk,  both  alkaline  fluids,  can  hold  in  solution  these  salts 
which  are  naturally  insoluble  in  alkaline  or  even  neutral  liquids.  Lime 
phosphate  is  to  some  extent  soluble  in  lactic  or  hydrochloric  acid,  and 
thus  we  see  how  small  quantities  taken  into  the  stomach  may  diffuse  into 
the  blood,  but  large  amounts  would  pass  unchanged  through  the  alimen- 


PHOSPHORUS    AND    ITS    COMPOUNDS.  65 

tary  canal,  so  that  if  we  employ  it  medicinally  only  small  doses  can  be 
of  service. 

When  excluded  from  the  food  the  bones  have  been  observed  to  soften, 
though  Weiske's  experiment  already  alluded  to  show^s  that  this  is  not  al- 
ways the  case.  Milne  Edwards  found  the  bones  of  animals  which  had 
been  fractured  united  more  rapidly  when  this  salt  was  given  and  clinical 
experience  shows  corroborative  evidence  of  this.  Chossat  produced 
softening  by  withholding  all  lime  salts.  The  lime  phosphate  is  further 
important  as  a  nutrient,  being  apparently  essential  to  the  growth  of  tis- 
sue. Even  when  excess  of  lime  afterward  preponderates,  as  in  the  shells 
of  animals,  this  salt  seems  necessary  to  initiate  the  growth,  for  the 
carbonate  cannot  entirely  replace  it.  Wherever  growth  is  active  there 
the  lime  phosphate  is  present  in  excess.  Not  only  is  this  the  case  in  nor- 
mal growth  but  even  in  abnormally  rapid  cell-development  the  same  ex- 
cess is  found.  This  phosphate  is  eliminated  slowly.  Neubauer  and 
Beneke  reckon  0.4  gramme  a  day  by  the  renal  secretion,  a  little  more  es- 
capes from  the  bowels,  but  that  may  be  only  undigested  residue  of  food. 

Phosphate  of  lime  has  been  largely  used  in  medicine,  first  whenever 
there  has  seemed  to  be  deficiency  in  the  bony  system,  as  in  mollities  os- 
seum,  delayed  dentition,  and  in  rachitis.  It  is  true  there  is  often  no  defi- 
ciency in  the  food,  but  still  the  presentation  of  an  unusually  abundant 
supply  might  act  as  a  stimulant  to  its  absorption.  But  this  treatment 
has  not  been  so  successful  as  was  hoped.  Rickets,  indeed,  is  not  merelv 
deficiency  of  phosphates,  and  all  the  symptoms  of  this  disease  are  not 
produced  in  animals  by  excluding  the  salt  from  the  diet,  even  when  the 
l)ones  lose  their  solidity.  In  rickets  there  is  malnutrition  of  other  tis- 
sues as  well  as  the  osseous,  and  although  this  salt  may  play  some  part  in 
their  nutrition,  and  therefore  be  rationally  prescribed,  cod-liver  oil  is  as 
good  or  better.  The  phosphate  generally  suits  better  after  the  tender- 
ness of  the  cartilages  has  subsided,  that  is,  when  the  activity  of  the  dis- 
ease has  passed  by.  The  secretions  are  generally  too  acid  and  the  earthy 
})hosphate  would  moderate  this  condition,  while  the  unusual  degree  of 
acidity  would  render  it  soluble.  It  would  hardly  seem  necessary,  there- 
fore, to  combine  it  with  an  acid,  as  some  have  proposed  in  this  disease,  in 
which  excess  of  acidity  would  tend  to  dissolve  the  osseous  salts  and  so 
promote  their  elimination  rather  than  their  deposit. 

This  phosphate  is  next  employed  in  defective  cell-growth  and  other 
manifestations  of  its  insufficient  action.  It  is  true  the  salt  may  not  be 
absent  from  the  food  or  even  decreased  in  quantity,  but  either  it  is  not 
absorbed  or  the  tissues  for  some  reason  are  not  using  it.  In  such  cases 
of  malnutrition  the  phosphate  is  often  excreted  in  excess.  Beneke 
found  this  to  be  often  the  case  in  scrofulas,  and  it  has  been  observed  in 
various  conditions  of  ill-health.  What  we  want  is  to  find  out  why  it  is 
not  assimilated  and  if  possible  remove  the  cause.  To  give  it  by  the 
5 


66  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

stomach  when  excretion  is  excessive  could  at  best  only  provide  for  the 
waste,  and  this  has  been  compared  to  the  administration  of  sugar  in  dia- 
betes. But  the  comparison  is  scarcely  just,  surely  the  practice  rather  re- 
sembles giving  iron  in  anaemia,  and  we  know  that  this  is  often  useful 
when  there  is  no  deficiency  of  the  metal  in  the  diet.  The  presentation 
of  abundance  may,  in  the  one  case  as  in  the  other,  stimulate  the  sluggish 
assimilation.  The  phosphate  is  itself  sometimes  useful  in  ansemia,  especi- 
ally in  rapidly  growing  young  persons,  as  well  as  in  hyperlactation,  ex- 
cessive suppuration,  and  exhaustive  discharges.  Sometimes  also  in  hectic 
and  in  chronic  wasting  diseases  in  which  there  is  excessive  elimination, 
a  kind  of  phosphaturia  which  sometimes  accompanies  scrofula,  large  ab- 
scesses, leucorrhcea,  caries  and  necrosis  of  bone — in  a  word,  wherever 
growth  or  repair  is  unusually  active,  calling  for  the  presence  of  the  salt. 
This  medicine  has  also  been  employed  in  chronic  bronchitis  and  in  phthi- 
sis, but  in  these  diseases  it  has  of  late  years  been  displaced  by  the  hypo- 
phosphites. 

As  a  good  deal  is  taken  in  the  food  and  as  little  is  required  it  would 
almost  seem  that  the  best  way  of  administering  the  remedy  would  be  to 
take  care  that  the  diet  contained  a  free  supply.  Then  it  may  be  added 
to  the  food,  to  farinaceous  articles,  or  to  milk,  in  the  hope  that  the  stom- 
ach will  take  up  as  much  as  may  be  required,  and  the  surplus,  which 
passes  into  the  intestines,  will  be  innocuous.  It  has  been  said  that  it  is 
more  easily  dissolved  when  mixed  with  table-salt,  and  this  would  natu- 
rally be  taken  with  the  food.  Some  have  thought  that  when  obtained 
from  organic  structures  it  is  more  easily  assimilated  than  when  deposited 
as  a  mineral,  hence  the  favor  with  which  filings  of  bone  and  ivory  have 
sometimes  been  regarded.  Others  have  found  the  salt  derived  from  the 
vegetable  kingdom  equally  efficacious.  Dusart  and  Blache  recommend 
an  acid  preparation,  lacto-phosphate,  which  is  freely  soluble  and  may 
often  be  useful,  but  as  we  have  already  hinted,  there  are  cases  in  which 
the  secretions  are  too  acid,  but  in  which  the  ordinary  salt  may  seem 
indicated. 

Magnesium  phosphate  accompanies  the  sister  salt,  but  mostly  in 
smaller  quantities.  Thus  there  is  considerably  less  in  bone,  blood,  and 
milk  ;  but  there  is  more  of  the  magnesium  salt  in  muscle,  and  in  brain 
about  twice  the  amount.  Although  one  may  not  entirely  replace  the 
other,  their  action  is  probably  very  similar  ;  this  substance  is  eliminated 
by  the  kidneys  at  the  rate  of  about  0.6  gramme  a  day,  bringing  up  the 
amount  of  the  two  earthy  phosphates  together  to  about  one  gramme, 
while  of  the  soluble  alkaline  phosphates  about  4  or  4.5  times  as 
much  is  excreted.  The  magnesium  phosphate  is  sometimes  employed  in 
conjunction  with  the  calcium  and  for  similar  purposes. 

Sodium  and  Potassium  Phosp/hate. — These  are  often  distinguished 
as    the  alkaline  phosphates,    they    are    soluble    to    the   extent    of    four 


PHOSPHORUS    AND    ITS    COMPOUNDS.  67 

per  cent,  in  water,  and  so  can  be  given  in  solution.  They  are  important 
in  the  blood  and  intercellular  fluids.  There  is  this  difference  between 
them  :  the  basic  phosphate  of  soda  gives  to  the  blood  its  alkaline 
quality,  and  is,  moreover,  endowed  like  alkaline  carbonates  with  the 
power  of  absorbing  carbonic  acid  and  so  carrying  off  this  gas  ;  on  the 
other  hand,  the  acid  phosphate  of  potassium  is  found  in  the  muscular 
juice,  where  perhaps  it  promotes  the  transudation  of  nutrient  matter 
(thus  opposing  the  effect  of  the  basic  soda  salt  in  the  blood),  and  so  the 
solution  of  worn-out  tissue.  It  will  thus  be  seen  that  the  functions  of 
these  two  phosphates  are  very  different.  They  are  eliminated  to  some 
extent  in  mucus  and  perspiration,  but  most  of  all  by  the  kidneys.  In 
the  renal  secretion  a  part  of  the  alkaline  sodic  salt  is  replaced  by  an  acid 
biphosphate,  which  gives  to  the  fluid  its  acid  reaction,  although  it  con- 
tains no  free  acid.  It  is  supposed  that  the  urate  of  sodium  is  formed  at 
the  expense  of  the  phosphatic  base,  uric  acid  taking  the  soda  it  requires 
and  leaving  the  basic  phosphate  thus  converted  into  a  biphosphate,  to 
be  eliminated  and  render  the  secretion  acid.  According  to  Wood,  the 
alkaline  phosphates  are  increased  during  mental  exertion,  but  the  earthy 
are  diminished,  so  that  the  total  amount  is  not  much  changed.  On  the 
other  hand,  he  found  the  earthy  phosphates  increased  during  abstinence 
from  mental  labor.  The  earthy  salts  are  held  in  solution  by  the  acid  of 
the  secretion,  and  when  this  reaction  is  absent  or  much  diminished  they 
are  thrown  down  as  a  light  precipitate.  The  alkaline  phosphates  being 
freely  soluble  never  disturb  the  transparency  of  the  fluid.  It  is  in  these 
salts  that  most  of  the  phosphoric  acid  is  excreted.  Some  phosphoric  acid 
is  probably  formed  in  the  body  by  oxidation,  for  phosphorus  is  taken  in 
food,  but  is  entirely  oxidized  in  the  system,  and  the  phosphoric  acid  thus 
formed  leaves  chiefly  in  union  with  soda,  with  a  little  superabundance  of 
acid.  Daremberg  found  that  phosphates  were  also  eliminated  in  the  ex- 
pectoration, and  in  regard  to  this,  that  there  were  remarkable  differences 
between  cases  of  bronchitis  and  phthisis  ;  he  found  in  phthisis  patients 
lost  as  much  phosphates  (and  chlorides)  by  the  sputa  as  by  the  kidneys, 
and  in  the  same  investigations  he  observed  that  a  bronchitic  loses  about 
two  per  cent,  of  nitrogenous  matter  in  his  expectorations,  while  a  con- 
sumptive loses  about  three  times  as  much  ("Doctor,"  1877).  Teissier  and 
others  have  also  drawn  attention  to  the  free  elimination  of  phosphates  by 
the  kidneys  in  consumption,  from  which  is  derived  one  argument  for 
their  administration  in  this  disease. 

Sodium  phosphate,  administered  in  large  doses,  acts  as  a  purgative, 
and  the  taste  is  not  objectionable  ;  it  is,  in  fact,  commonly  known  as  taste- 
less, purging  salt,  and  may  be  given  in  broth  instead  of  table-salt,  half 
an  ounce  to  an  ounce.  In  small  doses  it  has  often  been  employed  instead 
of  other  phosphates.  Dr.  William  Stephenson  considers  it  to  possess  a 
powerful  influence  on  the  biliary  secretion,  especially  in  young  children, 


68  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES.    ■ 

and  his  observation  is  confirmed  by  Professor  Bartholow  and  others. 
Three  or  four  grains  or  more  may  be  given  for  this  purpose,  according  to 
age,  with  milk  or  other  food.  It  may  be  used  for  the  same  purpose  in 
adults,  in  twenty  to  thirty  grain  doses,  with  the  food. 

Potassium  phosphate  has  not  been  so  largely  used.  It  is  a  white  de- 
liquescent salt,  which  crystallizes  with  difficulty.  It  may  be  employed 
for  the  same  purposes  as  the  sodium  salt,  and  has  recently  been  recom- 
mended in  phthisis  and  scrofula,  usually  in  conjunction  with  other  phos- 
phaites.     Dose  ten  to  thirty  grains,  three  times  a  day,  after  meals. 

Free  Phosphorus. 

The  history  of  the  therapeutical  use  of  uncombined  phosphorus  pre- 
sents a  curious  illustration  of  the  rapid  and  complete  changes  which  take 
place  in  medical  opinion.  Extolled  at  one  time  as  a  most  potent 
remedy  for  certain  special  and  intractable  diseases,  it  is  soon  after  found 
utterly  neglected,  to  be  brought  forward  again  after  a  lapse  of  time  as 
almost  a  panacea,  and  soon  after  again  to  fall  in  disfavor  to  await  another 
wave  of  opinion.  Some  years  ago  it  was  again  studied,  with  the  result 
of  achieving  considerable  popularity,  which,  perhaps,  attained  its  acme 
six  or  seven  years  since,  though  it  is  still  largely  prescribed,  its  place  in 
therapeutics  having  become  more  generally  recognized.  This  element 
enters  the  system  in  combination,  perhaps  with  albuminates,  but  most  of 
all  with  fats.  The  larger  the  amount  of  fat  present  the  more  rapid  will 
be  the  absorption.  It  is  supposed  that  some  may  enter  the  blood  unal- 
tered, and  that  some  may  be  more  or  less  oxidized,  for  in  cases  of  poi- 
soning it  has  been  found  in  the  form  of  hypophosphorous  acid,  of  phos- 
phorous acid,  and  of  phosphoric  acid,  moreover,  phosphuretted  hydrogen 
has  been  detected.  It  is  eliminated  by  the  liver  and  other  glands  ;  by 
the  skin,  lungs,  and  kidneys,  in  an  oxidized  form,  except  in  cases  of 
poisoning,  in  which  it  may  be  excreted  uncombined,  as  many  observers 
have  reported  that  the  excretions  have  been  rendered  phosphorescent. 
It  is  easy  to  see  that  unabsorbed  portions  may  pass  through  the  bowels, 
but  we  should  expect  that  in  the  renal  secretion  it  would  only  appear  as 
phosphates,  unless  under  very  exceptional  circumstances. 

■  The  vapor  of  phosphorus  is  a  local  irritant  to  mucous  membranes  and 
will  produce  inflammation.  On  the  periosteum  it  acts  so  powerfully  as 
to  produce  destruction  of  bone,  which  used  to  be  very  common  in  the 
match-maker's  disease.  Internally,  quite  small  doses,  continued  for  a 
time,  may  so  far  disturb  the  digestion  as  to  render  a  temporary  interrup- 
tion of  the  course  necessary.  On  the  nervous  system  it  exercises  a  slight 
excitant  influence,  and  some  still  consider  it  to  possess  a  distinct  stimu- 
lant action  on  special  parts.  Gubler  found  that  zinc-phosphide  set  free 
hydrogen,  even  in  artificial  digestion,  and  this  combined  with  the  phos- 


PHOSPHORUS    AND    ITS    COMPOUNDS.  69 

phorus  and  delayed  the  process.  In  large  doses  more  distinct  symptoms 
are  produced,  and  these  may  gradually  merge  into  the  poisonous  effects. 
The  most  remarkable  of  these  may  be  summed  up  as  profound  alteration 
of  the  viscera,  tissues,  and  blood,  combined  with  the  effects  of  corrosive 
poisoning.  The  gastro-enteric  inflammation  is  usually  attributed  to  the 
action  of  compounds,  but  this  explanation  seems  doubtful,  inasmuch  as  it 
has  occurred  after  the  introduction  of  the  element  directly  into  the 
blood.  The  duodenum  suffers  a  good  deal,  whence  the  irritation  is  prop- 
agated along  the  biliary  duct  ;  to  this  may  be  due  the  jaundice  which 
usually  occurs,  but  others  ascribe  this  to  the  action  on  the  liver,  in  which 
the  element  has  been  found  ten  hours  after  death  ;  others  consider  the 
jaundice  as  htemic.  The  liver  certainly  suffers  much  in  acute  phosphorus 
poisoning,  and  it  is  difficult  to  distinguish  the  effects  on  this  organ  from 
acute  yellow  atrophy  ;  in  protracted  cases,  also,  the  organ  atrophies  and 
resembles  the  effects  of  disease.  The  other  viscera  are  affected,  especially 
the  kidneys,  with  a  kind  of  fatty  degeneration,  which  process  probably 
extends  to  all  the  tissues,  since  Wegner  has  shown  it  to  involve  the  mi- 
nute arterioles.  The  blood  is  rapidly  deteriorated,  great  destruction  of  the 
red  corpuscles  is  produced,  the  haemoglobin  is  so  altered  as  no  longer  to 
give  its  proper  spectrum,  and  the  reactions  of  fibrinogen  and  the  fibrino- 
plastic  substance  are  hindered.  Ecchymoses  appear  over  the  body,  and 
hemorrhages  from  all  the  mucous  membranes  take  place  ;  in  fact,  a  kind  of 
hemorrhagic  diathesis  is  set  up,  combined  with  various  fatty  degenera- 
tions, which  in  protracted  cases  extend  to  the  involuntary  muscular 
system.  The  jaundice  appears  in  from  thirty-six  hours  to  four  or  five 
days,  according  to  Tilngel,  Lebert,  Wyss,  and  others.  Albumen  is  found 
in  the  urine,  and  sugar  has  been  detected.  The  bile  acids  also  appear, 
and  the  biliary  coloring  matter  as  soon  as  jaundice  sets  in  ;  also  leucin 
and  tyrosin,  and  (more  important  still)  sarcolactic  acid.  On  these  points 
Munk  and  Leyden,  as  well  as  Lewin,  Kohts,  Virchow,  Ossikovsky,  and 
others  previously  cited  agree,  notwithstanding  some  doubts  that  have 
been  thrown  upon  them.  Albuminuria,  however,  is  not  often  found  in 
animals,  even  though  the  kidneys  may  be  greatly  damaged  ;  and  cases 
do  occur  in  which  the  symptoms  differ  considerably.  One  is  mentioned 
by  Leidler,  in  which  suppression  of  urine  took  place,  and  death  in  a  few 
hours.  Mayer  says  that  where  very  large  doses  have  been  taken,  both 
the  urine  and  the  blood  may  be  phosphorescent.  Casper  says  that  gen- 
erally delirium,  paralysis,  coma,  and  convulsions  occur,  but  the  nervous 
system  often  gives  no  especial  signs. 

The  best  emetic  in  cases  of  poisoning  is  sulphate  of  copper,  as  it  com- 
bines with  the  element  to  form  a  less  active  phosphide,  as  shown  by  Eu- 
lenberg^  Guttman,  and  Bamberger.  Turpentine  appears  to  be  the  best 
antidote,  as  first  pointed  out  by  the  late  Dr.  Letheby,  who  was  led  to 
this  discovery    by  noticing  that   the  vapor  of  turpentine  prevented  the 


70  THERAPEUTICS    OF    THE    EESPIKATORY   PASSAGES. 

action  of  the  fumes  on  the  artisans  exposed  to  them.  After  his  sugges- 
tion MM.  Andant  and  Personne  soon  published  cases  showing  the  value 
of  the  turpentine.  It  unites  with  the  phosphorus  in  a  spermaceti-like 
mass,  which  is  soluble  in  ether,  alcohol,  and  alkaline  solutions,  and  can 
be  eliminated  by  the  kidneys  without  injuring  them.  It  is  the  common 
commercial  turpentine  which  is  alone  effective,  probably  because  it  is 
richest  in  ozone,  having  been  exposed  to  the  air.  This  turpentine  also 
seems  to  prevent  fatty  degeneration  of  the  tissues.  To  repair  the  dam- 
age to  the  blood  transfusion  is  recommended  by  Jurgensen  ;  of  course 
all  fatty  matters  must  be  withheld. 

The  question  now  naturally  arises  whether  a  substance  which  pro- 
duces such  effects  as  have  been  described  can  in  any  sense  be  called 
a  nutrient.  Certainly  it  can  only  be  in  a  special  sense  that  such  a  poi- 
son can  be  called  a  food.  Yet,  inasmuch  as  it  enters  into  the  tissues 
and  promotes  their  growth  it  is  to  them  a  nutrient  in  the  same  sense  as 
a  pliosphate  is.  Minute  doses  promote  the  growth  of  bone.  Wegner  has 
shown  that  under  their  influence  the  epiphyseal  cartilages  ossified  more 
quickly  and  more  completely,  new  deposit  took  place  on  the  inside  of 
the  shafts  of  the  long  bones,  and  this  to  such  an  extent  that  in  some 
instances  the  medullary  cavity  was  filled  up.  The  effect  was  more 
marked  in  growing  than  in  adult  animals.  The  new  tissue  is  at  first 
gelatinous.  If  the  animal  were  deprived  of  lime  the  new  tissue  was 
formed  notwithstanding,  but  remained  soft  ;  no  excess  of  phosphates 
appeared  in  the  bone,  and  no  such  action  could  be  obtained  from  phos- 
phoric acid  unless  given  in  proportional  doses,  nearly  a  thousand  times 
larger.  Hence  Wegner  concludes  that  it  acts  in  its  elemental  form, 
not  after  oxidation. 

Phosphorus  is,  moreover,  a  very  important  constituent  of  nervous 
tissue.  Is  it  therefore  a  nutrient  to  that  ?  The  excitement  caused  by 
medicinal  doses  points  in  that  direction.  Gubler  thought  the  excite- 
ment more  marked  than  that  produced  by  coffee  or  opium,  and  Dr.  Ash- 
burton  Thompson  compares  it  to  the  stimulus  of  alcohol  without  its 
subsequent  depression.  These  statements  seem  to  me  highly  colored. 
Dr.  Gowers  made  a  very  important  observation  if  it  be  confirmed  in 
other  cases.  He  found  in  lymphoma  the  number  of  the  red  corpuscles 
increased  under  the  influence  of  phosphorus.  This  is  very  unlike  what 
might  be  anticipated  from  the  toxic  effects  by  which  the  corpuscles  are 
destroyed  and  the  hsemaglobin  so  altered  as  no  longer  to  give  its  char- 
acteristic spectrum.  We  see  rather  arrested  nutrition  combined  with 
fatty  degeneration  than  any  nutrient  effect,  but  this  it  may  be  said  is 
because  we  have  to  do  with  a  poison  which  may  nevertheless  in  minute 
quantities  supply  a  want  or  stimulate  nutrition. 

How  then  does  it  act  ?  The  irritation  in  the  alimentary  canal  may 
be  due  to  compounds.     After  absorption  its  affinity  for  oxygen  has  been 


PHOSPHORUS    AND    ITS    COMPOUNDS.  7l 

conjectured  by  Lecorche  and  Eulenberg  to  bring  about  a  kind  of  as- 
phyxia, but  this  seems  an  untenable  hypothesis,  for  turpentine,  its  anti- 
dote, oxidizes,  and  Crocq  employed  oxygen  with  success  to  prevent  its 
poisonous  effects.  Gubler  suggests  that  it  acts  by  its  ozonizing  power, 
as  though  only  a  little  oxygen  could  be  lost  to  respiration,  the  re- 
mainder mixed  with  the  ozonized,  may  be  believed  to  be  so  much  more 
active  as  to  be  able  to  stimulate  the  system  and  bring  about  increased 
activity,  and  so  rapid  waste,  especially  of  the  blood-globules.  Phosphu- 
retted  hydrogen  not  only  impairs  digestion,  Dybkowskv  found  it  de- 
stroyed haemoglobin  and,  like  phosphoric  and  other  acids,  produced  fatty 
degeneration  of  the  tissues.  This  gas  might  readily  be  formed,  the 
hydrogen  being  easily  obtained  from  water,  so  other  phosphides,  or  the 
more  unstable  hypophosphites  might  be  produced  in  the  system. 

The  use  of  phosphorus  in  diseases  of  the  osseous  system  may  be  de- 
duced from  what  has  preceded.  It  has  been  rather  extensively  tried 
instead  of  the  phosphates,  but  it  is  in  diseases  of  the  nervous  system  that 
it  has  recently  obtained  considerable  repute,  acting  as  a  nerve  tonic  and 
stimulant  and,  as  some  maintain,  a  kind  of  food  to  nervous  tissue, 
Kabuteau,  in  face  of  all  the  evidence  that  has  been  adduced,  says  he 
does  not  hesitate  to  assert  that  it  has  never  cured  anything,  but  has 
always  been  useless,  and  he  never  means  to  prescribe  it.  On  the  other 
hand,  Dujardin-Beaumetz  reports  wonderful  results,  and  his  observations 
are  confirmed  by  a  number  of  London  physicians,  who  believe  that  it  is 
of  essential  service  in  neuralgia,  neurasthenia,  paralysis,  spinal  irrita- 
tion, ataxia,  etc.  As  a  stimulant  in  the  exhaustion  of  fevers  it  was  in 
use  more  than  a  hundred  years  ago.  Bayle  considered  it  indicated 
wherever  death  was  imminent  from  failure  of  vital  force  without  much 
structural  change,  and  particularly  in  putrid  fevers  and  the  exanthe- 
mata. He  also  recommended  it  in  pneumonia  where  there  was  great 
depression,  and  in  the  recent  revival  of  its  use  it  has  been  employed 
freely  in  this  disease,  particularly  when  it  attacks  old  persons  or  robust 
adults,  in  whom  it  is  said  there  is  more  frequently  nerve-depression  than 
in  the  young  or  the  feeble.  It  is  during  extreme  prostration  that  the 
most  marked  effect  is  recorded,  but  it  is  also  used  at  later  periods,  e.g., 
when  red  hepatization  is  complete  and  the  fever  and  exhaustion  seem  to 
increase,  but  suppuration  has  not  begun.  After  pus  has  formed  it 
should  be  withheld.  It  may  also  be  given  in  retarded  convalescence, 
when  there  is  no  longer  any  febrile  excitement.  Dr.  Ashburton  Thomp- 
son advises  large  doses  in  this  disease,  and  attributes  the  good  results 
of  the  older  authorities  to  their  full  doses,  as  the  toxic  effects  were  less 
known  to  them.  Certainly,  to  act  as  a  powerful  stimulus  minute  doses 
at  long  intervals  could  not  be  relied  upon,  but  it  would  surely  be  safer 
to  repeat  small  doses  than  to  run  the  risk  of  producing  toxic  effects.  If 
phosphorus  be  used  at  all  for  this   purpose   there  can  be  no  reason  for 


72  THERAPEUTICS    OF   THE   RESPIRATORY    PASSAGES. 

resorting  to  the  heroic  doses  sometimes  recommended.  When  adminis- 
tered in  convalescence  it  is  almost  always  advisable  to  give  iron  at  the 
same  time.  In  chronic  pneumonia  and  bronchitis  it  is  much  less  useful, 
though  occasionally  prescribed  in  the  early  or  late  stage,  or  when  there 
is  very  little  expectoration,  and  it  should  not  be  given  when  there  is  any 
tendency  to  hemorrhage.  It  has  been  recommended  in  pleurisy  attack- 
ing persons  injured  by  alcohol,  but  there  is  little  if  any  evidence  of  its 
utility. 

In  phthisis,  much  as  it  has  been  vaunted,  it  should  be  used  only  with 
considerable  caution.  It  is  likely  to  bring  on  haemoptysis  wherever  a 
tendency  to  that  exists.  It  is  not  suitable  in  febrile  conditions,  and 
great  care  should  be  taken  lest  it  interfere  with  digestion,  on  account  of 
the  extreme  importance  of  promoting  nutrition.  It  is  reputed  to  relieve 
the  cough  and  expectoration,  as  well  as  night-sweats  and  colliquative 
diarrhoea.  Perhaps,  when  the  cough  is  rather  dry  it  is  more  appropriate 
than  when  the  expectoration  is  free.  When  it  agrees  it  will  improve  the 
appetite  and  perhaps  promote  digestion,  and  thereby  relieve  irritative 
attacks  of  diarrhoea  ;  but  when  this  symptom  is  due  to  ulceration  it  is 
useless,  and  at  the  stage  when  this  occurs  the  remedy  seems  inappropri- 
ate. All  the  good  effects  of  the  phosphatic  salts  have  been  alleged  to  be 
dependent  on  the  phosphorus,  but  this  view  cannot  be  maintained,  and  it 
is  important  to  discriminate  between  them. 

Phosphorus  has  been  recommended  on  very  unsatisfactory  grounds  in 
fatty  degeneration,  leukasmia,  lymphadenoma,  and  other  diseases  in 
which  it  seems  quite  unsuitable,  but  into  discussion  concerning  which  we 
cannot  here  enter. 

The  form  in  which  it  is  given  is  important,  the  first  thing  is  to  avoid 
offending  the  stomach  or  disgusting  the  patient  with  his  cod-liver  oil. 
Solutions  in  oil  oxidize  by  keeping  ;  an  ethereal  solution  seems  very  un- 
suitable, as  the  ether  may  evaporate,  and  leave  the  solid  phosphorus  in 
the  mouth  or  elsewhere.  The  pill  of  the  British  Pharmacopoeia  is  very 
insoluble,  and  has  frequently  been  known  to  pass  through  the  system  un- 
changed. Suet  or  other  fat  may  be  used  as  an  excipient.  The  phos- 
phide of  zinc  is  preferred  by  some  prescribers  ;  whatever  preparation  be 
used,  it  should  be  given  with  the  food. 

Hypophosphites. 

These  salts  have  been  introduced  to  supersede  phosphorus  as  well  as 
the  phosphates,  and  it  has  been  held  that  they  are  valuable,  both  with 
regard  to  the  base  and  the  acid,  it  being  claimed,  for  instance,  that  cal- 
cium hypophosphite  possessed  the  virtues  of  phosphorus  on  the  one  hand 
and  the  lime  salts  on  the  other.  The  hypophosphites  were  brought 
prominently  forward  by  Dr.  Churchill,  of  Paris,  as  curative  in  phthisis, 


PHOSPHORUS  and  its  compounds.  73 

but  his  statements  have  not  been  fully  verified,  and  in  this  country  are 
generally  regarded  as  exaggerated.  Some  consider  that  they  are  oxidized 
and  so  only  useful  as  phosphates  ;  we  must  admit,  however,  that  a  dis- 
tinction has  been  established,  and  that  they  in  some  degree  derive  their 
virtue  from  the  loosely  combined  phosphorus.  Toxicological  records 
show  that  hypophosphoric  acid  may  be  found  in  the  blood  in  cases  of 
phosphorus  poisoning,  and  we  know  of  no  reason  why  the  same  acid 
could  not  be  absorbed  in  small  quantities,  except  the  admitted  instability 
of  the  acid  and  its  salts. 

Clinical  observation  seems  rather  in  favor  of  their  use,  and  Dr. 
Thorowgood,  who  has  had  large  experience  of  them,  recently  informed 
me  that  his  conviction  of  their  utility  remained  unchanged.  Many  years 
ago  he  selected  for  me  some  of  the  cases  which  he  deemed  suitable  then 
under  my  care  at  the  North  I^ondon  Consumption  Hospital.  These  were 
placed  on  the  hypophosphites  without  other  treatment,  with  a  view  to 
comparing  their  progress  with  that  of  the  other  in-patients  who  were 
treated  by  the  usual  methods.  I  cannot  say  that  much  difference  was 
perceived  ;  but  there  is  this  difficulty  in  all  such  experiments — patients 
coming  into  a  well-ordered  hospital  and  provided  with  good  food,  medi- 
cal necessaries,  and  every  comfort,  are  likely  to  improve  at  once,  and  that 
in  proportion  to  the  want  and  exposure  to  which  they  have  been  previ- 
ously subjected.  The  cases  most  likely  to  be  benefited  are  those  of 
early  phthisis  without  pyrexia  or  any  tendency  to  haemoptysis,  or  else 
cases  of  chronic  or  fibroid  phthisis.  Perhaps,  too,  they  may  be  useful  in 
cachectic  conditions,  in  which,  however,  free  phosphorus  would  probably 
be  more  certain.  Little  benefit  can  be  anticipated  from  them  in  bron- 
chitis, emphysema,  or  pneumonic  phthisis.  They  maybe  regarded  as  nu- 
trients, or  at  any  rate  as  substances  which  perhaps  stimulate  nutrition  ; 
when  they  thus  act  they  promote  digestion  and  increase  the  appetite, 
and  in  such  cases  of  course  are  beneficial  ;  whenever  they  impair  the  ap- 
petite they  will  to  that  extent  only  be  injurious. 

Dr.  Thorowgood  thinks  that  under  the  use  of  the  hypophosphites  (and 
phosphorus)  he  has  seen  pleuritic  thickenings  melt  away,  and  consolida- 
tions of  the  lung  of  two  or  three  months'  standing  disperse,  while  cases 
which  looked  to  him  and  others  very  like  acute  tubercle  in  the  lungs, 
have  recovered  under  hypophosphites.  In  pulmonary  diseases  of  inflam- 
matory exudative  origin,  and  apt  to  run  into  phthisis,  he  knows  no  rem- 
edy to  compare  to  the  hypophosphites.  In  a  note  to  the  Sritish  Medical 
Journal,  June  21,  1884,  he  confesses,  however,  that,  as  with  other  drugs, 
some  cases  resist  it,  and  he  thinks  it  is  the  bacillus  which  sets  the  remedy 
at  defiance,  for  it  is  in  those  cases  in  which  the  hypophosphites  are  most 
helpless  that  his  clinical  clerk  usually  finds  "  lots  of  bacilli." 


CHAPTER  X. 
AIDS    TO   DIGESTION. 

Leaving  now  the  ingredients  of  food,  we  pass  to  certain  substances 
already  mentioned,  which  as  they  are  materially  concerned  in  digestion 
may  be  considered  as  direct  promoters  of  nutrition.  The  digestive  fer- 
ments artificially  extracted,  and  their  allies  or  substitutes,  have  become 
largely  employed  as  therapeutical  agents.  It  is  interesting  to  observe 
that  although  the  process  of  digestion  has  only  been  understood  in  recent 
times  there  were  attempts  to  utilize  the  gastric  fluids  at  a  very  early  pe- 
riod. Pliny  tells  us  that  liquids  taken  from  the  stomachs  of  sucking 
animals  were  used  for  medical  purposes,  and  Asclepiades  recommended 
such  a  fluid  to  assist  the  removal  of  large  coagula  of  milk.  Galen,  too, 
tells  us  he  had  personally  experienced  the  value  of  such  a  remedy,  and 
observed  that  boiling  destro^'ed  it,  as  he  had  found  that  fowls'  stomachs 
were  rendered  inert  by  cooking.  The  milk  and  fluid  taken  from  the 
stomachs  of  sucking  animals  continued  to  be  used  for  centuries,  and  was 
ia  the  London  Pharmacopoeia  of  16TT  ;  the  issue  of  1721  contained 
among  its  remedies  the  lininsf  membrane  of  a  fowl's  stomach — which 
shows  us  how  old  is  an  idea  which  has  of  late  years  been  again  brought 
forward.  In  1783  Spallanzani  published  his  remarkable  experiments  on 
digestion,  after  which  gastric  juice  became  still  further  studied,  and  prep- 
arations from  it  were  said  to  have  been  used  by  Laennec.  The  discovery 
of  pepsin,  of  course,  displaced  the  disgusting  preparations,  and  gave  an 
immense  impetus  to  the  use  of  such  aids  to  digestion.  In  some  parts  of 
England,  rennet  has  for  generations  been  a  popular  domestic  remedy. 

Extract  of  malt  may  be  first  named,  as  it  is  commonly  considered  a 
substitute  for  ptyalin,  and  this  it  is  so  far  as  the  diastase  goes,  but  we 
must  not  forget  that  it  is  also  a  direct  nutrient  on  account  of  the  con- 
siderable proportion  of  dextrose  and  glucose.  So  that,  when  cod-liver 
oil  cannot  be  taken,  extract  of  malt  is  often  advantageously  given  as  a 
nutrient,  in  which  case  it  should  be  given  with  the  food.  Of  course  we 
are  here  speaking  of  genuine  extract,  not  of  the  porter  or  stout  which  is 
sometimes  sold  under  that  name.  The  extract  mixes  well  with  milk. 
For  its  diastatic  use  it  should  be  given  with  farinaceous  food.  It  is  an 
invaluable  emulsifying  agent,  especially  for  cod-liver  oil. 


AIDS    TO    DIGESTION.  7o 

Pepsin  and  Pancreatin. — These  two  ferments  are  sometimes  pre- 
scribed together,  but  the  practice  is  not  to  be  commended.  We  have 
seen  how  different  is  the  action  of  the  two,  which  can  never  replace  each 
other  ;  in  fact  it  would  seem  that  pepsin  is  capable  of  digesting  pancrea- 
tin, although  it  is  doubtful  if  a  converse  process  can  be  partially  effected. 
This  we  know,  the  gastric  juice  is  acid  and  in  it  pepsin  is  active  ;  it 
seems  therefore  natural  that  the  use  of  this  substance  should  prove  bene- 
ficial in  retarded  or  difficult  digestion.  It  is  easy  enough  to  introduce 
pepsin,  and  if  necessary  acid  also,  into  the  stomach  at  the  time  food  is 
taken,  so  as  to  reinforce  the  gastric  juice.  It  seems  to  me,  also,  that  it 
is  not  necessary,  as  some  have  supposed,  to  introduce  enough  to  digest 
all  the  food  taken  ;  for  it  may  well  be  that  the  presence  of  some  pepsin 
may  stimulate  further  secretion.  If  we  suppose  the  gastric  glands  to  be 
incapable  of  any  action,  of  course  a  small  quantity  of  pepsin  could  only 
digest  the  due  proportion  of  proteids.  Probably  the  dose  of  pepsin 
should  usually  be  larger  than  that  generally  prescribed  ;  it  should  also 
bear  some  proportion  to  the  proteids  taken.  Dr.  King  Chambers  seems 
to  have  arrived  at  a  similar  conclusion  from  clinical  experience,  and 
therefore  he  says  give  it  to  those  consumptives  who  cannot  digest  half 
a  chop  without  it,  and  then  it  can  be  given  until  a  whole  chop  can  be 
digested,  when  he  thinks  it  will  have  done  all  it  can.  I  cannot  quite 
endorse  this,  for  if  so  much  can  be  done  in  a  few  days  as  in  some  of  his 
cases,  it  seems  more  might  be  effected  still  in  others.  One  difficulty 
with  which  we  have  to  deal  is  that  in  natural  digestion  the  pepsin  is  not 
all  poured  on  the  food  at  once.  By  the  movements  of  the  stomach  its  con- 
tents are  successively  exposed  to  the  action  of  the  gastric  juice  as  they 
come  in  contact  with  the  walls.  To  imitate  this  it  seems  to  me  that  we 
may  sometimes  take  the  pepsin  in  successive  portions,  but  most  patients 
think  it  hard  enou2:h  to  swallow  a  sino-]e  dose  of  medicine  with  a  meal 
and  could  scarcely  be  persuaded  to  sip  it,  as  they  mostly  object  to  the 
taste  of  the  liquids.  At  my  suggestion  Messrs.  Savory  &  Moore  have 
prepared  a  powder  which  may  be  taken  in  the  place  of  table-salt  ;  it  is,  in 
fact,  a  mixture  of  pepsin  with  salt,  but  has  to  be  prepared  in  a  special 
way,  as  an  ordinary  mixture  of  salt  and  pepsin  is  apt  to  decompose.  The 
sphere  of  pepsin  is  to  assist  the  solution  of  proteids  in  the  stomach,  and 
as  soon  as  it  passes  the  pylorus  its  power  is  arrested  by  the  bile  and  other 
fluids  and  the  acidity  essential  to  its  action  is  replaced  by  an  alkaline 
reaction. 

Pancreatin,  on  the  other  hand,  comes  into  action  at  this  stage,  and 
the  doubt  naturally  suggests  itself  whether  it  can  reach  the  duodenum 
unaltered  when  administered  by  the  mouth.  Defresne  and  others  have 
alleged  that  it  may  pass  through  the  stomach  without  being  destroyed, 
its  action  being  merely  arrested  for  a  time  and  restored  when  it  finds  it- 
self in  an  alkaline  medium  ;   but  this   is  opposed  to  the  teachings  of  our 


76  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

laboratory  experiments,  which  rather  indicate  a  probability  of  its  destruc- 
tion. To  avoid  this  it  has  been  proposed  to  administer  it  in  an  alkaline 
solution  an  hour  or  two  after  the  meal.  But  this  interval  would  scarcely 
suffice  ;  at  that  time  there  would  be  plenty  of  acid  in  the  stomach  to  neu- 
tralize an  ordinary  dose  of  alkali.  To  secure  its  passage  unaltered  the 
stomach  should  be  empty,  and  if  delayed  so  long  it  might  possiby  be  too 
late  to  be  of  much  service.  Some  have  said  that  given  on  an  empty 
stomach  it  would  necessarily  provoke  an  immediate  secretion  of  gastric 
juice  ;  but  there  is  no  proof  of  this,  and  we  have  already  seen  that  iron 
introduced  through  a  gastric  fistula  may  not  provoke  secretion  enough  to 
dissolve  it.  Then,  again,  many  physiologists,  with  whom  we  must  agree, 
admit  that  water  may  at  once  pass  through  the  pylorus.  It  has  therefore 
appeared  to  me  possible  to  obtain  what  we  desire  by  a  nice  calculation 
as  to  time  of  administration.  Perhaps,  as  we  know  that  pancreatic  juice 
begins  to  be  poured  out  at  the  commencement  of  a  meal,  it  is  not  unphysi- 
ological  to  introduce  it  immediately  before  eating,  with  a  draught  of  water 
to  assist  its  progress.  A  further  precaution  might  be  taken  by  enclosing 
it  in  capsules  or  pills  with  a  coating  easily  soluble  in  a  weak  alkaline. 

Peptonized  Foods. — There  is  no  doubt  about  our  ability  to  secure  to 
some  extent  the  action  of  either  pepsin  or  pancreatin  upon  the  food  before 
it  is  eaten,  and  the  recent  extensive  adoption  of  that  method  may  be  re- 
garded as  a  distinct  advance.  I  can  fully  endorse  the  statements  of  Dr. 
William  Roberts  in  his  "  Lumleian  Lectures."  I  have  derived  the  great- 
est benefit  from  peptonized  and  pancreatized  foods.  It  is  true  these  sub- 
stances are  only  partially  digested,  but  the  completion  of  the  process  is 
rendered  easy  in  the  stomach,  and  assimilation  thereby  promoted.  A 
little  attention  will  enable  any  one  to  keep  up  a  supply  of  pancreatized 
milk,  avoiding  on  the  one  hand  insufficient  action,  and  on  the  other  the 
development  of  too  pronounced  a  bitterness.  How  easily  an  invalid's  meal 
of  a  farinaceous  food  may  be  thinned  by  a  teaspoonful  of  succus  pancre- 
aticus  almost  immediately,  enough  to  make  it  drinkable,  is  by  this  time 
pretty  well  known. 

mie  is  still  retained  as  a  medicinal  agent,  though  it  is  much  less  fre- 
quently employed  than  formerly.  It  is  supposed  to  be  useful  not  only 
as  an  aperient,  but  as  supplying  the  place  of  the  secretion  when  de- 
ficient. But  a  study  of  the  nature  and  uses  of  bile  and  the  amount 
usually  secreted  does  not  give  much  support  to  such  a  notion.  The  ad- 
dition of  five  or  ten  grains  of  the  purified  fel-bovis  to  the  large  quantity 
of  bile  secreted  in  twenty-four  hours  could  scarcely  have  much  effect. 
Probably  the  bile-salts  are  of  importance  from  their  property  of  facilitat- 
ing the  passage  of  fat  through  membranes,  and  no  doubt  bile  materially 
assists  pancreatic  digestion,  but  further  information  is  needed  on  the 
subject,  and  the  saline  constituents  of  the  secretion  have  not  yet  come 
into  use  as  medicines. 


AIDS    TO    DIGESTION.  77 

Feeding  by  the  Nose  or  Rectum. — Sometimes  it  is  not  merely  necessary 
to  assist  the  digestion  of  food,  but  to  introduce  it  by  unusual  routes. 
Those  who  have  much  experience  in  throat  diseases  know  how  often  deg- 
lutition becomes  almost  impossible.  Stricture  of  the  oesophagus,  again, 
prevents  the  entrance  of  nutriment.  Liquid  food  may  be  often  introduced 
through  a  fine  tube  passed  through  the  nostrils.  Often  it  becomes  our 
duty  to  institute  feeding  joer  rectum.  In  this  case  the  use  of  peptonized 
foods  is  most  important,  and  can  scarcely  be  too  highly  valued.  Lately 
dried  blood  has  also  come  into  use  for  rectal  alimentation,  and  it  has  been 
proposed  to  revive  an  ancient  practice  of  administering  this  fluid  by  the 
stomach.  I  remember  many  years  ago  tliat  Dr.  De  Pascale  tried  to  es^ 
tablish  at  the  abattoir,  at  Nice,  the  plan  of  drinking  fresh  warm  blood, 
and  he  bravely  set  the  example  morning  after  morning  of  quaffing  a  glass. 
He  was  followed  by  a  few  faithful  patients,  but  the  remedy  did  not  be- 
come popular,  and  I  suggested  to  him  that  it  should  perhaps  be  regarded 
as  a  ferruginous  nutrient,  inasmuch  as  it  would  be  digested  by  tlie 
stomach,  not  absorbed  unchanged.  Dried  blood  presents  less  difficultv, 
perhaps,  to  the  taste,  and  is  very  convenient  for  rectal  alimentation.  Dr. 
Andrew  H.  Smith  brought  the  preparation  before  the  New  York  Academy 
in  1879,  and  his  favorable  opinion  was  endorsed  by  a  committee  of  the 
Therapeutical  Society.  Dr.  H.  F.  Campbell  holds  that  a  reversal  of  the 
ordinary  peristaltic  movement  takes  place  when  aliment  is  introduced  ^er 
rectum,  tliough  Dr.  Austin  Flint  {American  Practitioner,  January,  1878), 
inclines  to  think  that  true  digestion  may  take  place  from  increased  secre- 
tion of  sficcics  eiitericus.  Dr.  Craven  has  produced  a  reliable  preparation 
which  Dr.  Sansom  has  used  at  the  London  Hospital  [Lancet,  1880).  Leube 
("Ziemssen's  Cyclop.,"  vii.)  considers  that  all  rectal  foods  should  be  pan- 
creatized,  and  his  emulsion  has  been  extensively  used  with  the  greatest 
benefit.  It  is  certainly  desirable  to  employ  the  most  easily  assimilated 
preparations,  and  among  these  pancreatic  emulsions  combined  with  finely 
minced  cooked  meat,  in  the  manner  advised  by  Leube,  stand  pre-eminent. 
The  sanguis  bovinus  exsiccatus  does  not  contain  the  fibrin  and  some  other 
principles,  and  cannot  be  said  really  to  represent  the  fresh  bullock's  blood, 
though  it  may  perhaps  be  more  nutritious  than  a  solution  of  the  iron 
salts  of  the  blood. 

Forced  feeding  by  the  stomach  has  given  some  remarkable  results  to 
Debove  and  Dujardin-Beaumetz,  who  have  demonstrated  clinically  the 
importance  of  nutrients  in  convalescents,  in  chronic  diseases,  and  most 
important  of  all  in  phthisis.  The  systematic  feeding  in  nervous  diseases 
employed  by  Weir  Mitchell  is  a  further  illustration  of  this,  but  the  re- 
sults in  phthisis  are  perhaps  more  unexpected.  All  suitable  nutrients 
may  be  thrown  into  the  stomach  in  small  quantities,  at  frequent  intervals, 
even  after  that  organ  has  become  so  unaccustomed  to  the  presence  of 
food,  as  to  a  large  extent  to   have  lost  its  digestive    power,  of  which  the 


78  THERAPEUTICS    OF    THE    KESPIRATORY    PASSAGES. 

best  and  most  certain  restoration   is   food.     This  is  to    be  given  in  small 
quantities,  which  can  be  increased  gradually. 

Stimui.ants  to  Digestion. 

Certain  substances  may  be  separated  from  previously  considered  di- 
gestives, inasmuch  as  they  act  rather  by  stimulating  the  digestive  pro- 
cess. Among  these  may  be  first  named  our  ordinary  condiments  (from 
condio,  I  season),  such  as  pepper,  salt,  spices,  pickles,  and  other  agree- 
able or  tasty  additions  to  food.  Some  of  these  are  sialagogues  (o-taXov, 
saliva,  ayw,  I  expel),  and  may  therefore  be  useful  by  increasing  the 
quantity  of  ptyalin.  Others  are  the  aromatics,  so  named  from  their 
fragrancy  (apw/Aa,  an  odor).  The  more  distinctly  medicinal  ones  are 
sometimes  called  carminatives  {carmen,  a  verse  or  charm)  and  they  cer- 
tainly allay  spasmodic  pain  and  dispel  flatus.  Most  of  them  contain 
some  essential  oil  or  volatile  principle,  which  stimulates  the  gastric 
mucous  membrane,  and  abates  spasm  of  the  muscular  coat,  so  tending  to 
restore  the  ordinary  peristaltic  movements.  They  are  therefore  used  to 
relieve  the  pain  set  up  by  distention,  and  also  to  prevent  that  condition. 
Moreover,  they  are  useful  stimulants  to  the  digestive  process  in  atonic 
dyspepsia.  Another  class  of  remedies  allied  to  the  foregoing  are  the 
bitters,  as  we  often  call  them,  from  their  characteristic  taste,  and  which 
apparently  act  as  gentle  stimulants  to  the  stomach  and  thus  tend  to  in- 
crease the  appetite.  For  similar  purposes  other  general  tonics  are  also 
used,  such  as  bark,  quinine,  nux  vomica,  strj'chnia,  etc.,  each  possessing 
its  own  characteristic  action  on  the  system.  In  the  same  way  acids  are 
employed,  either  alone  or  in  combination  with  tonics.  Allied  to  these, 
astringents  may  be  also  named  as  in  turn  useful.  Then,  again,  we  may 
employ  alkalies  as  digestives,  inasmuch  as  small  doses  administered 
shortly  before  a  meal  provoke  an  increased  secretion  of  gastric  juice,  and 
so  contribute  in  suitable  cases  to  assist  digestion  and  therefore  nutrition, 
although  their  characteristic  action  is  rather  that  of  denutrients.  Sto- 
machic sedatives  may  also  be  named,  such  as  bismuth  and  lime,  which 
seem  to  act  directly  on  the  mucous  membrane,  and  which  therefore,  in 
appropriate  cases,  are  also  promoters  of  digestion  and  so  of  nutrition. 
In  connection  with  the  last  class  we  may  mention  general  sedatives  and 
anodynes,  which  may  be  called  in  to  act  locally  on  the  stomach.  From 
the  foregoing  illustrations  it  will  be  perceived  that  most  diverse  remedies, 
acting  either  upon  the  stomach  directly  or  through  the  s^'stem,  may, 
under  various  circumstances,  be  appropriately  prescribed  as  likely  to 
promote  nutrition  by  beneficially  influencing  the  digestive  process,  a  fact 
which  explains  why  some  aperients,  like  rhubarb  and  aloes,  are  also  re- 
puted to  be  digestive  tonics. 


CHAPTER  XI. 

TRANSFUSION. 

When  it  is  no  longer  possible  to  introduce  nutriment  into  the  ali- 
mentary canal,  or  when  this  way  is  insufficient,  it  is  still  possible  to  re- 
sort to  transfusion,  an  operation  more  frequently  performed  to  prevent 
death  by  hemorrhage.  It  was  natural  to  use  blood  for  this  purpose,  but 
other  liquids  have  been  successfully  employed.  In  1656  Sir  Christopher 
Wren  infused  wine  and  opium  into  the  circulation  of  a  dog,  and  soon 
after  Lower  transfused  blood  from  the  vessels  of  one  dog  into  those  of 
another.  In  1667  the  first  transfusion  on  a  human  subject  was  per- 
formed at  Montpellier,  in  France,  by  Denis  and  Emmerez,  who  employed 
the  blood  of  lambs  and  calves.  In  1668  Fracassati,  Manfredi,  and  Riva 
followed,  employing  the  blood  of  healthy  men.  The  early  successes  were 
so  signal  that  the  practice  became  abused,  and  sad  catastrophes  took 
place.  Great  opposition  was  excited,  and  the  French  Legislature  in 
1675  forbade  the  operation.  In  1776  Kohler  employed  with  success 
venous  injection  of  emetics  to  remove  a  piece  of  gristle  impacted  in 
the  gullet.  His  example  was  followed  by  Balck,  and  at  intervals  bv 
others,  until  the  discovery  that  hypodermic  injection  would  be  sufficient 
for  this  purpose.  Hennmann  injected  an  infusion  of  bark  and  ammonia 
into  the  veins  of  a  patient  who  seemed  dying  from  fever,  and  he  recov- 
ered. The  late  Dr.  J.  Blundell  revived  the  operation  at  Guy's  Hospital 
about  1815,  with  brilliant  success,  for  tlie  details  of  which  we  mav  refer 
to  his  "Researches,"  1824,  and  to  the  "  Medico-Chirurgical  Transac- 
tions," 1818.  Dieffenbach  in  1828  used  defibrinated  blood,  and  intro- 
duced the  terms  mediate  and  immediate  transfusion  ;  soon  after  this 
O'Shaughnessy  proposed  to  inject  saline  fluids  into  the  veins  of  cholera 
patients,  and  this  was  done  in  the  epidemic  of  1830  by  Dr.  Latta  in 
Edinburgli,  Majendie  in  France,  .Tanichen  in  Moscow,  and  several  others 
in  London,  among  them  Drs.  Sweedie,  Murphy,  Girdwood,  Craigie, 
Arthur  ;  but  most  important  of  all  by  Dr.  Little,  whose  remarkable  re- 
coveries in  the  London  Hospital  demonstrated  the  power  of  the  remedy, 
and  in  a  later  epidemic  his  son.  Dr.  L.  S.  Little,  also  obtained  excellent 
results.  At  the  same  hospital  Drs.  Woodman,  Heckford,  and  others 
have  also  adopted  this  practice,  and  it  has  been  shown  that  in  many  cases 


80  THERAPEUTICS    OF   THE    RESPIRATORY   PASSAGES. 

the  use  of  saline  fluids  may  advantageously  replace  blood,  and  this 
even  in  cases  where  the  operation  has  been  performed  to  prevent  death 
from  hemorrhage.  The  fluid  employed  by  Dr.  Little,  and  subsequently 
by  his  son,  was  composed  of  chloride  of  sodium,  60  grains  ;  chloride  of 
potassium,  6  grains  ;  phosphate  of  soda,  3  grains  ;  carbonate  of  soda,  20 
grains ;  alcohol,  2  drachms  ;  distilled  water,  1  pint.  Large  quantities 
were  introduced  ;  in  some  of  the  most  successful  cases  as  much  as  four 
pints,  at  a  temperature  of  110°  F.  It  was  found  that  the  blood-globules 
preserved  their  natural  appearance. 

When  blood  is  employed  for  transfusion,  small  quantities  are  used, 
most  frequently,  perhaps,  about  six  ounces,  but  it  is  better  to  inject 
cautiously  three  ounces,  and  if  that  is  well  borne,  gradually  increase  it  to 
double,  or  even  to  eight  or  ten  ounces.  The  question  of  defibrinating  has 
been  freely  discussed,  and  will  be  differently  answered  by  different  oper- 
ators, a  good  deal  depending,  perhaps,  on  the  instrument  emplo^'^ed.  It  is 
certain  that  many  of  the  corpuscles  may  be  left  after  defibrination,  but 
it  seems  almost  equally  certain  that  when  thus  supplied  they  soon  under- 
go disintegration  and  excretion,  so  that  they  would  appear  not  to  be  o£ 
the  use  that  has  been  supposed.  The  fibrin,  too,  is  regarded  by  some  as 
useless  and  effete,  and  they  therefore  think  it  is  better  to  avoid  the  pos- 
sibility of  introducing  a  fibrin  ferment.  Panum  and  others,  therefore, 
employ  simply  blood-serum  ;  at  first  sisrht  it  may  seem  that  pure  blood 
or  its  serum  would  be  the  most  natural  fluid,  and  moreover  would  prove 
a  valuable  nutrient,  such  as  could  not  be  supplied  by  saline  solutions 
only  ;  and  this,  if  so,  would  of  course  render  blood  transfusions  more  ef- 
fective in  certain  cases  in  which  more  than  the  saline  ingredients  of  the 
blood  are  needed.  Recent  experiments,  however,  seem  to  show  that  the 
regeneration  of  red  corpuscles  is  more  active  after  the  transfusion  of 
salines  than  of  serum  or  blood  itself,  and  the  operation  is  certainly 
simpler. 

We  have  seen  that  the  blood  of  animals  has  been  successfully  em- 
ployed, but  this  is  less  appropriate,  and  it  appears  that  the  degeneration 
of  the  corpuscles  is  more  certain,  and  perhaps  more  rapid  in  such  a  case. 
With  a  view  of  introducing  a  nutritious  fluid,  Gaillard  Thomas,  Hodder, 
and  others  have  made  use  of  milk,  and  many  successful  cases  have  been 
reported,  but  even  this  fluid  is  declared  by  Culcerq  and  others  to  be 
dangerous,  inasmuch  as  agglomerated  milk-corpuscles  may  give  rise  to 
fatty  embolism.  One  reason  assigned  for  the  failure  of  certain  milk  in- 
jection is  the  difficulty  of  securing  the  purity  and  the  freshness  of  the 
fluid.  Dr.  Meldon  used  goat's  milk,  as  he  was  thus  enabled,  by  bringing 
the  animal  into  the  patient's  room,  to  use  the  milk  without  loss  of  time. 
Miglioranza,  in  the  Archives  Italiennes  de  Biologie  (torn,  iv.,  fasc.  2), 
condemns  the  injection  of  milk,  and  finds,  from  numerous  experiments, 
that  when  thus  employed   the  albuminoid  and  fatty  matters  are  excreted 


TRANSFUSION.  81 

Dy  the  kidneys,  but  that  if  any  considerable  quantity  is  present  it  pro- 
duces violent  vonuting  and  diarrhoea  with  prostration  and  often  death. 
Even  when  previously  filtered,  milk  produced  these  symptoms,  with  chv- 
luria  and  fatty  infiltration  of  the  kidneys.  Albertone  proposed  to  use 
the  serum  of  milk,  and  in  fact  did  so,  without  ill  effects.  These  observers 
consider  that  the  cases  pronounced  successful  by  others  must  be  due  to 
the  small  quantity  of  milk  injected,  and  Laborde  has  found  that  even 
such  small  quantities  may  give  rise  to  serious  mischief.  It  may  be  worth 
while  to  add  here  that  Miglioranza  found  carbonate  of  ammonia  injected 
into  the  veins  produced  excitement  of  the  circulation,  dyspnoea,  hyperses- 
thesia,  tetanic  convulsions,  and  coma,  in  fact,  urjBmic  fever  or  ammoni- 
semia,  although,  as  we  have  seen,  small  quantities  of  ammonia  have  cer- 
tainly been  used  without  ill  effect.  Halford  has  indeed  often  injected 
solution  of  ammonia^  into  a  vein,  as  a  remedy  in  cases  of  snake-poisoning, 
and  recommends  it  to  be  done  by  means  of  a  hypodermic  syringe.  It 
would  seem,  then,  that  milk  requires  to  be  digested  before  entering  the 
circulation.  Blood,  however,  does  not,  but  there  are  difficulties  about 
transfusion  of  this  fluid,  and  it  seems  by  no  means  certain  that  by  intro- 
ducing it  we  supply  the  nutritive  elements  which  we  anticipate  ;  but 
the  saline  constituents  of  this  fluid  may  be  employed  with  greater  facility 
and  are  capable  of  producing  rapid,  nay,  immediate  and  sometimes  even 
startling  effects.  Schwartz  maintains  that  the  chief,  if  not  the  only  use 
of  transfusion  is  to  restore  vascular  tension,  and  accordingly  that  the 
quantity  of  the  liquid  is  more  imnortant  than  the  quality.  This,  of  course, 
refers  to  its  use  for  hemorrhage,  when  tiie  heart  ceases  to  act  because 
sufficient  fluid  is  not  poured  into  its  cavities,  but  on  injecting  a  saline 
fluid  we  re-establish  vascular  tension  and  so  restore  the  circulation.  In 
other  cases,  when  the  object  is  to  supply  something  more  nutritious,  this 
reasoning  will  not  apply.  Milk  is  evidently  no  safer  than  blood,  and 
perhaps  for  purely  nutritive  purposes,  inasmuch  as  in  such  cases  tliere 
is  time  to  Inake  preparations  deliberately,  immediate  transfusion  offers 
us  the  best  resource,  while  in  the  appalling  cases  of  hemorrhage,  for  which 
the  operation  has  been  most  frequently  performed,  saline  injections  prom- 
ise well.  To  render  the  operation  desirable,  as  a  means  of  renewing  fail- 
ing nutrition,  what  we  need  is  a  fluid  which  could  represent  blood,  or 
perhaps  rather  its  incipient  condition — chyle. 

Transfusion  of  defibrinated  blood  into  arteries  instead  of  veins  was 
proposed  by  Albanese,  and  is  recommended  by  Hiiter  and  Asche,  who 
have  successfully  practised  it.  The  blood  having  to  pass  through  the 
capillaries  on  its  way  to  the  right  heart,  sudden  distention  of  the  auricle 
is  prevented,  and  the  danger  of  admitting  air  or  of  thrombosis  is  avoided. 
This  last  is  a  danger  more  present  to  the  mind  in  modern  times,  but  is 
less  likely  to  happen  with  defibrinated  blood.  Yet  the  statistics  collected 
by  Gesellius,  show  out  of  146  cases  without  defibrination,  79  :=  54.11  per 


82  THERAPEUTICS    OF    THE    EESPIRATORY    PASSAGES. 

cent,  Avere  successful,  while  out  of  115  cases  when  defibrinated  blood  was 
employed,  79  =  G8.70  per  cent,  were  unsuccessful.  At  the  New  York 
Practitioners'  Society,  December  5,  1883,  Dr.  Bull  said  that  he  had  in- 
jected saline  fluids  into  the  central  end  of  the  radial  artery,  because  after 
injecting  the  peripheral  end  serious  consequences  had  occurred,  such  as 
embolism  and  gangrene  of  the  hand,  and,  further,  because  it  needed  a 
great  deal  of  force,  while  the  fluid  flowed  into  the  central  end  without 
difficulty. 

Injections  into  Seeous  Cavities. 

It  has  been  abundantly  demonstrated  of  late  years,  that  the  perito- 
neum may  be  interfered  with  much  more  freely  than  might  have  been 
anticipated.  It  has  also  been  shown  that  absorption  takes  place  with 
great  rapidity  from  this  cavity,  and  a  number  of  medicines  have  been  in- 
troduced in  this  manner.  It  is  not  therefore  surprising  that  Ponfick, 
Nussbaum,  and  others  should  have  injected  defibrinated  blood  ;  the  j^rac- 
tice,  however,  is  not  without  danger.  Ponfick  first  published  three  cases 
{Berl.  Klin.  Woch.,  September,  1879)  of  pernicious  anaemia  so  treated. 
Bizzozero  and  Golgi  afterward  showed  that  the  operation  enriched  the 
blood  in  luTeinoglobin.  Burresi  collected  38  cases,  in  24  of  which  it  was 
thought  to  have  done  good,  in  7  the  result  was  neutral,  but  in  7  it  did 
harm.  Foa  and  Pellacapi  have  traced  the  path  of  the  corpuscles  through 
the  lymphatics  of  the  abdominal  glands  and  diaphragm  into  the  blood- 
vessels. Much  more  recently  experiments  have  been  made  by  Dr.  Ber- 
nardino Silva  upon  rabbits,  in  order  to  determine  how  far  absorption  of 
defibrinated  blood  would  take  place  from  the  pleura.  From  ten  experi- 
ments he  concludes  (lievista  Cllnica,  October  and  November,  1883)  that 
1,  absorption  proceeds  as  well  as  through  the  peritoneum  ;  2,  the  effects 
of  the  injection  of  homogeuseous  blood  are  seen  in  an  increase  of  haemo- 
globin and  in  the  number  of  red  globules  within  four  or  five  hours  after 
the  injection,  and  are  prolonged  for  more  than  four  days  afterward  ;  3, 
the  greatest  increase  in  lu^moglobin  takes  place  within  the  first  twenty- 
four  hours  ;  4,  the  absorption  of  haemoglobin  is  greatest  Avhen  the  quan- 
tity of  blood  injected  is  small,  if  so  much  blood  is  injected  as  to  produce 
atelectasis  no  increase  of  hsemoglobin  is  observed  ;  5,  the  transfusion  of 
blood  into  the  pleural  cavity  causes  an  increase  in  the  excretion  of  urea — 
an  increase,  however,  which  is  preceded  by  a  diminution  during  the  first 
twenty-four  hours.  This  last  conclusion,  the  author  says,  needs  further 
confirmation.  In  a  note  at  the  end  of  his  article  Dr.  Silva  states  that 
Professor  Bozzolo  has  made  an  inter-pleural  transfusion  in  the  human 
subject,  with  beneficial  results,  in  a  case  of  anaemia  cojnplicated  with 
cachexia,  ascites,  anasarca,  and  albuminuria. 


TRANSFUSION.  83 


Hypodermic  Injections  of  Blood  and  Food, 

Dr.  Carlo  Bareggi  published  in  Milan  in  1882  a  prize  essay  on  the  hy- 
podermic injection  of  blood,  which  he  maintained  might  be  advantageously 
used,  either  defibrinated  or  not,  and  which  would  certainly  appear  to  be 
safer  than  the  previously  named  operations.  From  experiments  on  ani- 
mals he  proceeded  to  clinical  investigation.  He  found  one  gramme  abso- 
lutely innocuous,  but  larger  quantities  produced  in  man  slight  febrile  re- 
action, lasting  from  a  few  hours  to  at  the  most  two  days.  He  says  the 
red  globules  are  absorbed,  in  part  at  least,  unaltered.  Their  course  is  from 
the  lymphatic  spaces  in  the  connective  tissue  into  the  lymphatic  vessels 
leading  from  the  part,  through  the  glands  met  with  on  the  way  (unless 
these  are  in  an  advanced  stage  of  fibro-adipose  degeneration,  or  in  some 
other  way  profoundly  altered),  and  thence  into  the  receptaculum  chyli 
and  thoracic  duct.  They  were  found  in  the  principal  lymphatic  trunks 
of  the  part  twenty  minutes  after  the  injection  was  practised,  and  even 
after  three  days  numbers  of  them  in  a  good  state  of  preservation  were 
encountered  in  the  thoracic  duct.  The  greatest  number  was  met  with 
twelve  hours  after  the  injection,  but  even  after  fifteen  days  quantities  of 
red  globules,  but  little  changed,  were  seen  passing  from  the  cellular  tissue 
into  the  circulation.  x\bsorption  of  the  mass  of  injected  blood  proceeded 
rather  slowly  in  individuals  in  whom  the  circulation  was  sluggish,  es- 
pecially in  those  in  whom  there  Vv-as  considerable  subcutaneous  adipose 
tissue,  but  more  rapidly  under  normal  conditions  of  the  heart's  action 
and  in  persons  in  good  general  condition.  The  red  globules  were  un- 
changed after  remaining  many  days  in  the  cellular  tissue,  except  in 
cases  in  which  there  was  considerable  febrile  reaction.  He  considers  hy- 
podermic injections  of  blood  capable  not  only  of  arresting  the  progressive 
deterioration  in  the  quality  of  the  circulating  fluid,  caused  by  insufficient 
nourishment  or  repeated  losses,  but  also  of  increasing,  in  spite  of  such 
persistent  influences,  the  corpuscular  richness  of  the  blood.  But  to  ob- 
tain the  best  effects  injections  have  to  be  repeated  at  intervals  of  five  to 
fifteen  days  and  a  considerable  quantity  has  to  be  employed  each  time, 
three  and  sometimes  four  ounces.  And  moreover  we  may  observe  that 
when  iron  agrees  with  the  patient  the  increase  in  the  red  globules  pro- 
duced by  that  metal  is  almost,  if  not  quite  as  great.  Dr.  Paladini  has 
recorded  (  Gaz.  Med.  Ital.-Lomh.,  1883)  a  case  in  which,  the  patient  liv- 
ing in  a  remote  locality  and  being  in  a  critical  state,  he  injected  with  a 
common  syringe  about  one  hundred  and  thirty  grammes  (two  syringe- 
fuls)  of  blood  furnished  by  the  husband.  He  threw  it  into  the  subcuta- 
neous tissue,  about  four  fingers'  breadth  to  the  left  of  the  umbilicus, 
where  the  skin  was  lax  enough  to  be  raised  in  large  folds.  After  the 
operation   a   lump  the   size  of  a  lien's  q^^  was  felt,  but  disappeared  in 


84  THERAPEUTICS    OF   THE    RESPIRATOEY   PASSAGES. 

two  hours.     No  pain  or  inconvenience  was  produced  and  the  patient  did 
well. 

Hypodermic  injection  of  milk  and  other  alimentary  substances  has  also 
been  sometimes  resorted  to.  Dr.  Whittaker  {^Clinic,  1876)  reported  a 
case  supported  by  injections  of  milk  for  two  or  three  days,  two  drachms 
being  given  every  two  hours.  Afterward,  cod-liver  oil  was  used,  one  day 
four  ounces  being  introduced  in  eight  injections.  This  caused  no  pain  or 
inconvenience.     Two  small  abscesses  occurred  after  the  milk. 


CHAPTER   XII. 
WATEE— DILUENTS— BE^^RAGES. 

We  have  seen  the  extreme  importance  of  water  and  we  take  it  up 
here  because  it  stands,  as  it  were,  midway  between  constructives  and  de- 
structives, or  rather  acts  as  one  or  the  other  in  different  circumstances. 
It  is  the  one  necessary  beverage,  the  universal  solvent  and  diluent. 
Without  it  the  nutritive  principles  cannot  be  extracted  from  the  food, 
still  les-5  can  they  reach  the  tissues.  On  the  other  hand,  without  it  worn- 
out  tissue  cannot  be  dissolved,  and  therefore  cannot  be  carried  away 
from  the  place  where  it  is  useless.  Water,  then,  may  be  regarded  as  the 
carrier  into  and  out  of  the  body  ;  besides  which,  as  the  universal  lubri- 
cant, it  facilitates  all  molecular  changes.  As  the  carrier  into  the  economy 
it  presents  the  pabulum  to  the  tissues,  and  is  therefore  a  constructor, 
but  as  a  solvent  and  carrier  out  of  the  body  it  aids  disintegration  and 
removal,  though  this  last  action,  as  we  know,  within  due  limits  quickens 
construction.  Rapid  removal  calls  for  rapid  replacement,  waste  stimu- 
lates repair,  and  so  while  water  directly  promotes  construction  it  also 
stimulates  destructive  changes  and  removes  their  products.  It  is,  there- 
fore, truly  eliminant,  dissolving  all  substances  and  increasing  all  secre- 
tions and  excretions.  This  tends  to  loss  of  body  weight,  and  unless 
fresh  aliment  be  supplied,  this  will  take  place.  If  food  be  intercepted 
or  if  appetite  fail  the  waste  cannot  be  renewed.  But  moderate  water- 
drinking  usually  increases  appetite,  so  that  more  food  is  taken,  nutrition 
is  more  rapid,  and  instead  of  emaciation  the  opposite  results.  In  this 
case  it  would  prove  the  best  of  tonics,  but  in  default  of  food  or  appetite 
it  becomes  a  very  powerful  disintegrator,  and  it  has  been  believed  that 
in  this  way  it  may  be  utilized  to  remove  morbid  deposits,  though  this 
power  is  more  frequently  attributed  to  medicinal  water.  Drinking  in 
excess  may  itself  impair  digestion,  still  it  is  remarkable  how  large  quan- 
tities have  sometimes  been  taken  without  injury. 

In  health   an  adult  will  consume  on  an  average  nearly  four  pints  of 

.fluid  per  diem  ;   some  thirsty  souls  take  much  more,  others  do  with  less, 

A  few  make  simple  water  their  chief  fluid  ;  others  consume  much  milk  ; 

a  larger  number  take  a  considerable  proportion   of   tea,  coffee,  cocoa^  ©r 


8G  TUERAPEUTICS    OF    THE    EESPIRATORY    PASSAGES. 

other  simple  beverage  ;  too  many  almost  exclude  the  simpler  fluids  by 
the  amount  of  alcoholic  liquors  in  which  they  indulge.  In  this  last  case, 
of  course,  the  effect  of  the  alcohol  masks  that  of  the  fluid,  Vjut  we  must 
not  forget  that  the  amount  of  liquid  drunk  and  the  time  at  which  it  is 
taken  exercise  some  influence.  Of  course,  the  amount  of  liquid  received 
has  to  be  counterbalanced  by  that  removed,  so  that  the  skin,  lungs,  and 
kidneys  are  called  upon  to  get  rid  of  the  average  four  or  five  pounds  of 
water  a  day,  and  of  any  excess  that  may  be  ingested.  As  the  water  is 
taken  into  the  system,  and  is  the  vehicle  for  the  removal  of  waste,  it  may 
be  regarded  as  in  some  sense  washing  the  tissues.  It  is  commonlv  said 
that  a  very  little  water  passes  directly  through  the  pylorus,  but  I  agree 
with  Ktiss  in  the  opposite  opinion,  more  especially  when  large  quantities 
are  drunk. 

The  water  required  to  maintain  the  balance  of  the  system  is  only  a 
small  part  of  that  which  is  always  at  work  in  the  economy.  The  quan- 
tity daily  poured  into  the  alimentary  canal,  and  again  reabsorbed  by  the 
lymphatics  and  termini  of  the  vena  portse,  is  variously  estimated  at  from 
twelve  to  twenty-four  pounds — the  latter  quantity  being,  as  we  have  seen, 
the  estimate  of  Bidder  and  Schmidt.  This  water  is,  of  course,  the  pur- 
veyor of  various  dissolved  substances  which  are  precipitated  and  left  be- 
hind, and  the  solutions  in  question  must  contribute  their  share  to  the 
manufacture  of  the  chyle.  Water  passes  freely  from  the  stomach  into 
the  vena  porta?  ;  thence  it  goes  through  the  liver,  where,  becoming 
charged  with  the  products  of  that  organ,  it  brings  them  back  into  the 
intestines  where  they  are  precipitated.  Hence  we  may  understand  the 
repute  of  free  water-drinking  as  a  cholagogue  and  as  powerfully  assist- 
ing the  abdominal  circulation.  Apart,  therefore,  from  its  mechanical 
effect  in  the  primoe  viae,  which  varies  with  the  quantity  imbibed  at  a  time, 
water  may  be  regarded  not  only  as  a  solvent,  but  as  the  great  diluent 
and  eliminant.  It  dilutes  the  contents  of  the  stomach  and  intestines, 
and  thus  acts  as  an  aperient  ;  it  dilutes  the  bile,  and  thus,  as  we  have 
seen,  may  act  as  a  cholagogue  ;  it  dilutes  other  secretions,  and  thus  acts 
as  a  diuretic  and  diaphoretic.  Further,  it  dilutes  the  whole  mass  of  the 
fluids  ;  but  probably  the  blood  is  only  influenced  thus  for  a  brief  period, 
as  we  find  its  specific  gravity  is  maintained  with  tolerable  uniformity. 
Yet  the  rapid  introduction  of  liquid  into  the  circulation  undoubtedly 
tends  to  reduce  the  specific  gravity  of  the  blood,  and  that  whether  in- 
jected into  the  veins  or  absorbed  from  the  alimentary  canal.  At  the 
same  time  we  must  not  forget  that  the  excessive  inflow  excites  rapid  re- 
moval through  the  skin,  kidneys,  and  lungs,  in  order  to  maintain  the 
normal  balance.  Hence,  water  is  diaphoretic,  diuretic,  and  a  stimulant 
of  pulmonary  exhalation.  The  importance  of  this  balance  being  main- 
tained is  illustrated  by  the  fact  that  a  fall  in  the  specific  gravity  of  the 
plasma  causes  distention  of  the  red  corpuscles,  as  first  noticed  by  Hew- 


WATER — DILUENTS BEVERAGES.  87 

son  '  and  confirmed  by  Owen  Rees,^  who  also  established  the  converse 
effect  of  raising  the  specific  gravity.  Further,  medicines  which  hasten 
the  removal  of  water  from  tlie  system  by  quickening  secretion  indirectly 
produce  the  same  effects.  Water  may  further  be  regarded  as  a  regulator 
of  temperature,  inasmuch  as  the  surplus  heat  of  the  body  is  chiefly  dissi- 
pated by  its  evaporation.  Ilelmholtz  calculates  the  loss  of  heat  by  the 
evaporation  of  the  water  of  respiration  at  il.?  per  cent,  of  the  total  loss, 
and  the  amount  dissipated  in  conduction,  radiation,  and  evaporation  by 
the  skin  at  77.5  per  cent.  A  further  loss  of  5.3  per  cent,  is  accounted  for 
by  the  warming  of  the  expired  air,  the  balance  of  2.G  being  used  in  warming 
the  excretions.  Hence  it  is  clear  that  the  chief  temperature  regulator  is 
the  evaporation  of  water  through  the  skin  and  lungs.  With  regard  to  the 
lungs,  the  greater  the  quantity  of  air  that  passes  in  and  out  the  greater 
should  be  the  loss  of  heat  in  a  given  time  ;  but  this  effect  may,  perhaps, 
be  neutralized  by  heat,  producing  changes  in  the  lungs.  Further  the  con- 
clusion as  to  loss  of  heat  in  respiration  is  disputed,  but  as  to  the  loss  by 
the  skin  it  is  generally  admitted. 

The  temperature  at  which  water  is  drunk  materially  influences  its 
effect.  Absorption  appears  to  take  place  most  readily  at  or  about  the 
temperature  of  the  blood,  so  that  to  secure  rapid  removal  from  the 
stomach  by  absorption  it  should  be  taken  at  about  that  point,  and  in 
small  quantities  at  a  time  :  any  considerable  bulk  of  merely  tepid  water 
will,  indeed,  as  every  one  knows,  be  likely  to  cause  vomiting,  and,  in 
fact,  full  draughts  are  constantly  given  as  emetics.  Cold  water  in  small 
quantities  stimulates  the  stomach  and  assists  digestion,  but  a  full 
draught  is  apt  to  impede  that  function  ;  in  weakly  people  "  it  lies 
heav^y  "  for  a  long  time,  and  the  danger  of  drinking  very  large  quanti- 
ties, especially  when  the  body  is  hot  and  exhausted,  is  well  known.  A 
glass  of  cold  water  early  in  the  morning  is  an  excellent  aperient,  stimu- 
lating the  peristaltic  action  by  its  temperature,  and  promoting  the  se- 
cretions in  the  way  already  described.  Cold  water  may  be  given  even 
when  the  temperature  is  high,  and  it  does  not  give  rise  to  discomfort, 
but  is  usually  very  grateful.  On  the  other  hand,  warm  water  is  much 
more  grateful  in  many  painful  affections,  both  of  the  respiratory  and 
abdominal  organs  ;  it  is  better  to  increase  the  action  of  the  skin,  to 
promote  other  secretions,  and  possibly  to  stimulate  the  absorption  of 
morbid  deposits  ;  as  a  cholagogue  it  is  often  efficient  if  taken  regularly 
at  bedtime,  or  night  and  morning.  In  laryngitis  and  bronchitis  the  use 
of  hot  drinks  is  well  known  as  a  popular  remedy,  and  in  a  large  propor- 
tion of  respiratory  diseases,  both  acute  and  chronic,  warm  beverages  are 
more  appropriate  than  cold,  not  only  because  they  are  more  grateful  to 

'  Works  of  W.  Hewson,  F.R.S.,  edited  by  Gulliver.     London,  1846. 
»  Guy's  Hospital  Reports,  1841-2. 


88  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

the  patient,  but  because  they  promote  perspiration  and  afford  temporary 
"relief  to  cough  and  dyspnoea. 

The  systematic  use  of  warm  or  hot  water  dates  from  very  early 
times,  and  has  been  largely  carried  out  for  ages  at  the  various  hot 
springs.  It  therefore  excites  a  mild  curiosity  to  find  Dr.  Ephraim  Cut- 
ter claiming  on  behalf  of  another  American  physician,  Dr.  H.  Salisbury, 
the  merit  of  having  introduced  the  proper  use  of  this  remedy  in  1858. 
We  may  freely  admit  that  gentleman's  merit  in  carrying  out  a  series  of 
experiments  in  order  to  determine  the  best  mode  of  employing  this 
remedy,  without  forgetting  previous  labors  in  the  same  field.  Dr.  Salis- 
bury recommends  the  hot  water  to  be  drunk  regularly  four  times  a  day, 
from  one  to  two  hours  before  each  meal,  and  an  additional  dose  at  bed- 
time. The  quantity  usually  required  is  from  half  a  pint  to  one  pint, 
and  sometimes  a  pint  and  a  half  for  each  dose,  but  the  urinometer  is  to 
be  regularly  employed,  and  when  the  specific  gravity  of  the  urine  rises 
above  1.020,  more  is  required,  and  when  it  falls  below  1.015,  less  may 
be  taken.  Of  course  the  water  should  not  be  drunk  so  fast  as  to  cause 
distention,  but  sipped  during  a  quarter  or  half  an  hour.  The  effects  are 
described  as  quite  as  remarkable  as  those  of  the  most  potent  mineral 
springs.  Thirst  and  dryness  of  mucous  membrane  disappear  ;  the  skin 
puts  on  a  healthy  appearance  ;  the  urine  becomes  free,  pale,  and  resem- 
bles that  of  a  sucking  infant  ;  indeed,  all  secretions  become  healthy, 
digestion  rapidly  improves,  and  a  wonderful  elasticity  and  buoyancy  is 
perceived.  Dr.  Salisbury'  says  :  "If  I  were  confined  to  one  means  of 
medication  I  would  take  hot  water,"  and  Dr.  Cutter  tells  us  that  this  is 
stated  after  drinking  it  for  twenty-five  years,  and  he  himself  from  his 
personal  experience,  and  observation  corroborates  these  statements. 

An  eminent  medical  friend  of  mine  derived  remarkable  benefit  from 
a  plan  which  has  some  analogy  with  this.  Every  morning  he  had 
brought  into  his  consulting-room  a  jug  of  hot  water,  which  he  consumed 
during  the  intervals  of  his  consultations.  At  the  same  time  he  followed 
out  an  exact  system  of  diet.  I  could  record  various  instances  of  the 
value  of  warm  water,  and  for  that  matter,  of  cold  ;  but  from  what  has 
preceded  this  seems  unnecessary,  and  those  interested  in  the  subject 
may  be  referred  to  the  large  literature  respecting  mineral  waters,  as  well 
as  to  that  connected  with  hydropathy.  As  to  the  last,  it  is  unfortunate 
that  in  this  country  it  has  been  too  much  mixed  up  with  quackery, 
but  happily  there  are  now  many  qualified  medical  men  in  charge  of  hy- 
dropathic establishments,  and  the  follies  formerly  practised  are,  under 
their  guidance,  disappearing.  On  the  Continent  such  establishments 
Iiave  always  been  regarded  as  appropriate  spheres  of  professional  work, 
and  those  engaged  in  it  have  therefore  made  valuable  contributions  to 
science.  Water,  both  hot  and  cold,  is  an  invaluable  remedy,  both  exter- 
nally and  internally,   and   hydro-therapeutics,  therefore,  deserves  earnest 


WATER DILUENTS BEVERAGES.  89 

study,  but  we  cannot  countenance  the  exclusive  claims  which  have  some- 
times been  made  on  its  behalf,  and  we  deprecate  all  excesses — even  ex- 
cess in  drinking  so  simple  a  liquid  as  water,  whether  hot  or  cold. 

Beverages. 

As  the  vehicle  of  other  substances,  whether  nutritious  or  not,  water 
forms  the  bulk  of  all  our  beverages.  Some  of  these  contain  so  little  else 
that  they  can  only  be  regarded  as  simple  diluents,  but  in  others  we  find 
peculiar  principles  to  which  they  owe  their  distinctive  properties.  It 
may  be  convenient  to  group  them  accordingly, 

a.  Simple  Diluents. — Of  course,  pure  water  is  the  chief  of  these,  and 
at  one  time  some  patients  were  restricted  to  it  and  nothing  else,  either 
solid  or  fluid,  for  days  together.  DiUe  absolue  the  French  call  this, 
which  ousrht  to  be  translated,  not  literally,  but  as  want  of  food.  Toast- 
water  contains  so  little  as  to  merit  a  place  here,  as  may  any  drink  in 
which  there  is  but  little  nutriment  or  medicine,  such  as  the  slops, 
ptisans,  teas,  and    other  fluids  familiar  in  the  sick  room. 

b.  Mucilaginous^  such  as  oatmeal  water,  linseed  tea,  marsh-mallow 
tea,  and  the  other  demulcent  drinks  formed  from  gummy  or  farinaceous 
articles. 

c.  Saccharine  may  be  grouped  separately,  as  the  presence  of  sugar 
may  be  an  important  consideration  in  determining  tlieir  suital:>ility. 

d.  Liquid  foods,  such  as  milk,  beef-tea,  soups,  broths,  constitute  the 
most  nutritious  group,  being  capable,  when  properly  combined,  of  sup- 
porting the  system.      They  have  already  been*sufficiently  considered. 

e.  Aerated  drinks,  water  containing  carbonic  acid  enough  to  render 
it  effervescing,  forming  an  agreeable  cold  drink,  the  gas  acting  as  a 
stimulant  to  the  stomach. 

f.  Acidulous  drinks,  such  as  lemonade,  etc.,  are  often  very  grateful, 
and  are  believed  to  be  refrigerant  and  somewhat  astringent.  They 
quench  thirst,  tend  to  check  hemorrhage,  restrain  too  copious  perspira- 
tion, and  to  some  degree  abate  hectic  and  other  febrile  states.  Sub- 
acid fluids  may  to  a  considerable  extent  replace  this  group. 

g.  Salines. — In  one  sense  the  previous  group  resembles  this,  since  the 
acids  appear  in  the  blood  in  the  form  of  salts.  But  there  are  differences 
in  the  therapeutical  effects,  partly  due,  perhaps,  to  differences  in  quan- 
tity. Some  of  the  saline  domestic  remedies  are  but  convenient  modes  of 
administering  medicines,  and  now  and  then  it  is  necessary  to  beware  lest 
under  the  name  of  beverage,  active  medicines  should  be  too  freely  con- 
sumed. 

h.  Medicinal  Beverages. — Some  of  the  previous  groups  might  be 
placed  here,  for  both  acids  and  salines  are  potent  remedies,  as,  too,  are 
alkalies  and  others  which  may  conveniently  be  used  as  beverages.     Soda 


90  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

water  and  mineral  waters  to  wit,  but  only  with  due  regard  to  the  condi- 
tion of  the  system. 

i.  Fermented  Beverages. — Their  effects  may  be  referred  to  the  alcohol 
they  contain. 

h.  Tea  and  its  Allies. — We  come,  at  length,  to  those  beverages 
which  have  obtained  universal  favor  as  ordinary  articles  of  diet — tea, 
coffee,  cocoa,  mate  or  Paraguay  tea,  guarana,  coca,  or  rather,  as  Chris- 
tison  suggested,  cuca,  African  kola  nut,  etc.  These  are  mostly  used  as 
warm  infusions,  and  are  always  recognized  as  possessing  a  decided  influ- 
ence on  the  nervous  system.  These  vegetables  contain,  first,  a  volatile 
oil,  seldom  amounting  to  one  part  in  one  hundred  and  fifty,  but  that  is 
enough  to  impart  the  distinct  aroma  ;  second,  an  astringent  styptic  acid, 
allied  to  tannin,  which  amounts  to  thirteen  to  eighteen  per  cent,  in  tea, 
but  only  about  five  per  cent,  in  coffee  ;  third,  a  nitrogenous  alkaloid,  to 
which  is  attributed  most  of  the  effects  ;  this  is  called  tliein,  caffein,  theo- 
bromine, according  as  it  is  obtained  from  tea,  coffee,  or  cocoa  ;  but  all  are 
believed  to  be  identical.  The  amount  of  alkaloid  varies  in  the  different 
substances.  In  coffee  it  averages  0.75  per  cent.,  butPayen  found  as  much 
as  1.7  per  cent.,  though  no  one  else  has  detected  as  much  ;  in  tea  it 
averages  1.8  to  2  per  cent.,  but  in  some  good  specimens  there  is  much 
more,  Peligot  once  found  6.2  per  cent.,  and  Letheby  found  4.94  per 
cent,  in  a  sample  of  Himalayan  tea  ;  in  cocoa  1.2  to  1.5  per  cent.,  and  in 
the  leaves  of  this  plant  1.2  to  1.2G  -p^v  cent.;  in  mate  1,2,  and  in  guarana 
the  average  is  five  per  cent.  The  amount  present,  however,  may  not  cor- 
respond with  that  extracted.  Aubert  found  in  a  cup  of  coffee  made  with 
16. G6  grammes,  from  1.5  to  1.9  grain  of  caffein,  and  in  a  cup  of  tea 
made  from  five  to  six  grammes  of  the  leaf,  about  the  same  quantity  of 
alkaloid.  Cocoa  may  be  regarded  as  a  nutrient  combined  with  the  alka- 
loid, but  coffee  and  tea  are  rather  nerve-stimulants.  The  alkaloid  cer- 
tainly seems  to  produce  an  agreeable  excitation  of  the  nervous  system, 
without  the  subsequent  depression  which  characterizes  more  powerful 
stimulants  ;  moreover,  the  effect  is  more  prolonged.  These  facts  ex- 
plain the  high  value  so  universally  set  on  these  beverages,  as  well  as 
their  occasional  disagreement  with  a  few  individuals,  some  of  whom, 
however,  might  very  well  partake  of  them  if  they  would  employ  much 
weaker  infusions. 

Liebig  noticed  that  the  alkaloid  was  related  tokreatinin,  and  so  com- 
pared tea  and  coffee  to  soups  ;  being  related,  further,  to  nervous  tissue,  it 
might  be  suggested  that  it  would  serve  as  a  ready-prepared  nerve-food. 
But  it  is  not  likely  it  enters  into  the  formation  of  tissue.  Perhaps,  how- 
ever, it  mav,  on  account  of  its  near  relation,  serve  as  a  kind  of  stimulus 
to  change,  as  a  true  nerve-food  would.  Lehmann,  in  1854,  found  coffee 
reduced  the  excretion  of  urea,  and  therefore  he  concluded  that  it 
retarded  tissue  change,  and  in  this  he  seems  to  have  been  supported  by 


WATER — DILUENTS BEVERAGES.  91 

the  experiments  of  Bocker  and  Hoppe.  On  the  other  hand,  Volt  found 
no  such  adulteration  produced,  and  Dr.  Squarey's  numerous  experiments 
do  not  support  the  alleged  decrease.  The  evidence  as  to  tea  points  to 
a  slight  decrease,  but  is  not  very  satisfactory.  Dr.  Edward  Smith 
("  Phil.  Transactions,"  185D)  found  that  tea  and  coffee  increased  the  car- 
bonic acid  exhaled  by  the  lungs,  the  quantity  of  air  breathed  being 
increased,  the  respirations  being  deeper  and  freer.  This  would  indicate 
that  they  tend  rather  to  increase  than  to  retard  tissue  clianges.  He 
says  that  "  tea  promotes  all  vital  actions  and  increases  the  action  of  the 
skin,"  but  seems  to  think  that  coffee  diminishes  perspiration.  Probably 
both  infusions,  taken  warm,  promote  perspiration,  but  tea  more  decidedly 
so,  and  coffee  certainly  seems  rather  to  stimulate  the  kidneys.  In  pro- 
moting perspiration  they  would  indirectly  diminish  the  heat  of  the  bodv. 
The  alkaloid  is  not  the  sole  active  agent,  for  the  volatile  oil  has  been 
shown  to  produce  similar  symptoms.  It  causes  wakefulness,  abates*  the 
feeling  of  languor,  induces  perspiration,  and,  according  to  Lehmann, 
lessens  the  excretion  of  urea. 

We  may,  perhaps,  on  the  whole,  conclude  that  tea  and  its  allies  do 
really  retard  tissue  changes,  and  so  diminish  waste,  while  at  the  same 
time  they  certainly  excite  nervous  action,  and  thereby  render  work 
easier,  both  physical  and  mental,  but  more  especially  the  latter.  To  the 
cerebral  excitement  is  due  the  wakefulness,  the  persistent  thinking,  and 
the  feeling  of  cheerfulness  and  exaltation  which  are  characteristic  effects 
of  even  moderate  quantities  ;  and  poisonous  doses  expend  their  energy 
on  the  nervous  system. 

If  these  beverages  really  retard  tissue  changes,  we  can  understand 
why  they  are  reputed  to  abate  heat.  It  makes  some  difference  whether 
they  are  taken  warm  or  cold  ;  not  that  the  temperature  of  the  fluid  itself 
would  have  much  effect,  but  in  tlie  one  case  the  sensation  of  coolness 
may  be  grateful,  besides  prodscing  an  effect  through  the  nervous  svstem, 
and  in  the  other  the  promotion  of  evaporation  by  the  skin  and  lungs  in- 
creases the  escape  of  heat.  Are  we  then  to  regard  such  drinks  as  refrig-- 
erant,  even  when  warm?  Does  the  old  nurse's  tea  really  cool  her  as  she 
says  ?  Is  the  febrile  patient's  cry  that  it  cools  him  correct  ;  or  is  that 
idea  only  the  expression  of  thirst,  and  the  water,  not  the  tea,  the  active 
agent?  If  so,  may  we  not  give  the  water  and  leave  the  additional  ingre- 
dient to  the  patient's  choice — tea  or  warm  drinks,  acid  cool  drinks,  or 
fruits?  Practically,  we  know  that  any  refrigerant,  we  may  say  any 
pleasant  tasting  liquid,  is  grateful  to  a  heated  person,  whether  the  heat 
be  physiological  or  pathological.  Thus  we  find  in  thirst  with  warmth  of 
surface,  produced  by  exercise,  fluid  is  acceptable,  and  whether  cold  or 
warm  is  selected  is  often  a  matter  of  taste.  In  feverish  conditions,  no 
doubt,  there  is  excessive  production  of  heat,  not  merely  deficient  escape. 
Nevertheless,  any  increase  in  escape  give  proportionate  relief,  and  drink- 


92  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

ing  liquids  promotes  this.  The  cool  taste  of  the  cold  liquids  is  grateful 
in  itself,  while  the  warm  beverages,  perhaps,  act  by  their  indirect  effect 
on  the  skin,  for  the  simplest  hot  drinks  will  sometimes  at  once  unlock, 
as  it  were,  the  sweat-glands,  and  so  afford  relief.  This  is  particularly 
noticeable  in  affections  of  the  air-passages,  in  which,  even  when  acute  and 
attended  with  fever,  warm  fluids  are  preferred  and  are  most  beneficial. 
Perhaps  this  may  partly  arise  from  the  increased  elimination  of  water 
through  the  respiratory  mucous  membrane. 

Cuca. — The  leaves  of  the  Erj'throxylon  cuca  have  from  time  to  time 
had  ascribed  to  them  very  remarkable  qualities.  In  1609  Garcilasso  de 
la  Vega,  described  the  use  of  them  by  the  natives  of  Peru,  as  a  means  of 
preserving  strength  during  fatiguing  exercise  and  privation  of  food. 
Dr.  Mantegazza,  of  Milan,  whose  charming  travels  in  South  America  are 
pretty  well  known,  observed  that  it  increased  the  frequency  of  the  pulse, 
produced  a  strong  tendency  to  muscular  action  and  great  mental  vigor. 
Dr.  Von  Tschudi  partook  of  the  leaves  after  the  manner  of  the  Indians, 
and  found  they  prevented  difficulty  of  breathing  and  fatigue  in  ascending 
the  Andes,  as  well  as  enabled  liim  to  pursue  swift-footed  game  and  to 
endure  long  abstinence  from  food.  The  Indians  and  Peruvians  are  said 
to  run  fifty  miles  a  da}'  without  food  or  anything  except  their  cuca.  In 
1876  Sir  Robert  Christison  reported  to  the  Royal  Botanical  Society  of 
Edinburgh  experiments  on  liiinself  and  students.  The  veteran  professor 
havino-  found  that  a  fifteen  mile  walk  without  food  or  drink  was  sufficient 
to  tire  him,  proceeded  to  walk  sixteen  miles  in  three  stages.  He  chewed 
eighty  grains  during  his  second  rest,  and  forty  grains  in  the  last  stage  ; 
all  sense  of  weariness  vanished  and  he  reached  home  without  any  fatigue 
or  uneasiness.  Although  no  food  had  been  taken  for  nine  hours,  neither 
hunger  nor  thirst  was  felt,  but  he  did  justice  to  his  dinner,  had  a  good 
night's  sleep,  and  next  morning  was  free  from  fatigue.  On  another  occa- 
sion, after  ascending  three  thousand  feet  of  Ben  Voirlich,  fort}'  grains 
were  chewed,  and  all  fatigue  vanished,  the  descent  was  made  with  ease, 
another  twenty  grains  being  taken  when  half-way  down.  Neither  food 
nor  drink  was  taken  from  half  past  eight  in  the  morning  to  six  o'clock  in 
the  evening,  yet  neither  hunger  nor  thirst  was  felt,  no  drowsiness  was 
experienced  in  the  evening,  and  after  a  good  night's  sleep  he  awoke 
readv  for  another  day's  exercise.  He  concludes  that  cuca  removes  and 
prevents  fatigue,  and  suspends  hunger  and  thirst  without  eventually  af- 
fecting appetite  or  digestion.  It  seems  to  have  no  effect  on  the  mental 
faculties  except  liberating  them  from  the  dulness  and  drowsiness  which 
follow  great  bodily  fatigue.  We  should,  perhaps,  remember  that  Sir 
Robert's  splendid  mind  was  associated  with  a  body  always  remarkable 
for  its  activity  and  power  of  endurance,  and  young,  if  weakly,  persons 
could  not  hope  to  cope  with  the  aged  but  athletic  professor.  On  the 
publication  of  his  report  a  friend  of  mine  took  a  twenty  mile  walk  with 


WATER — DILUENTS BEVERAGES.  9o 

comfort  and  ease  on  sixty  grains  of  cuca,  and  said  he  felt  ready  for  an- 
other ;  he  took  neither  food  nor  drink  from  8  a.m.  to  4  p.m.,  and  felt 
neither  fatigue  nor  discomfort,  in  spite  of  inclement  weather.  Dr.  Bur- 
ness,  author  of  the  "  Specific  Action  of  Drugs,"  undertook  similar  experi- 
ments with  the  same  result,  and  he  informed  me  that  cuca  produced  a 
rise  in  the  temperature  ;  not  only  when  walking,  when  it  might  be  at- 
tributed to  the  exercise,  but  also  when  in  repose.  In  the  last  case  there 
was  a  rise  in  half  an  hour  after  a  dose  from  98.0°  to  99.3°  F.,  and  within 
the  next  half  hour  to  99.4°  F.,  after  which  it  again  gradually  fell.  Mr. 
Dowdeswell  reported  in  the  Lancet,  187G,  results  of  an  opposite  nature, 
and  some  others  have  failed  to  find  cuca  banish  fatigue  in  the  manner 
described  by  Christison.  The  leaves  contain  a  crystallizable  alkaloid  sim- 
ilar to,  if  not  identical  with  caffein,  besides  a  volatile  oil,  a  peculiar  waxy 
body,  and  an  astringent  substance  allied  to  tannin.  From  sixty  to  ninety 
grains  is  sufficient  for  one  trial  ;  it  is  uncertain  whether  it  retards  tissue 
change,  but  it  probably  does,  as  it  seems  to  diminish  the  excretion  of 
urea,  and  in  other  respects  resembles  in  its  properties  the  other  caffein- 
containing  plants,  but  it  does  not  seem  to  diminish  perspiration  nor  to 
produce  cerebral  excitement,  although  this  has  sometimes  occurred,  and 
very  large  quantities  have  been  followed  by  hallucination, 

Cucaine,  the  active  alkaloid  of  cuca,  has  been  given  in  one-eighth  and 
one-seventh  grain  doses.  In  some  respects  it  is  said  to  resemble  atropine. 
Dr.  Aschenbrandt,  during  the  manoeuvres  of  the  Bavarian  troops,  tried  it 
on  the  soldiers,  and  reports  that  one-seventh  of  a  grain  sufficed  to  remove 
fatigue,  hunger,  and  thirst,  so  that  the  men  could  go  for  hours  without 
food  or  drink.  He  considers  it  a  nerve-food.  His  observations  corrob- 
orate those  of  Dr.  Amess,  who  experimented  in  1880  with  chloride  of 
cucaine. 


CHAPTER   XIII. 

EXERCISE  AND  REST. 

We  have  seen  that  exercise  or  work  is  a  stimulus,  just  as  aliment  is, 
though  acting-  in  a  different  way.  This  is  most  familiar  in  the  muscular 
system.  We  can  increase  a  muscle  by  exercising  it  and  supplying  the 
body  with  aliment,  and  indeed,  under  the  influence  of  exercise,  nutri- 
ment may  be  drawn  from  other  parts  to  the  muscles  engaged.  Labor 
which  exercises  many  muscles  requires  a  proportionate  diet.  On  the 
other  hand,  daring  rest  in  bed  we  need  less  food.  A  familiar  instance  of 
this  is  an  accident,  say  a  broken  leg,  which  confines  a  healthy  person  to 
bed  ;  if  he  takes  the  same  food  as  in  active  life  febrile  symptoms  will 
set  in.  It  would  seem,  then,  that  exercise  would  be  a  nutrient,  or  rather 
would  promote  nutrition,  provided  proportionate  food  be  taken,  other- 
wise it  would  act  in  a  contrary  way.  The  effect  of  exercise  is  perceived 
in  all  organs,  but  the  expression  is  mostly  used  in  reference  to  the  loco- 
motor system.  The  muscles  in  contracting  accelerate  the  flow  of  blood 
and  so  act  on  the  circulation,  which  is  also  increased  from  the  general 
effect.  We  have,  therefore,  increase  of  heat,  more  frequent  pulse,  fuller 
respiration,  and  increased  secretion.  Another  more  distant  effect  is  the 
absorption  of  fat,  whether  from  increased  waste  or  from  pressure  exer- 
cised by  the  contracting  muscle  on  the  softer  tissues.  With  the  demand 
upon  it  the  muscle  grows,  increases  in  volume,  in  firmness,  in  elasticity, 
acquires  greater  strength.  As  the  muscular  action  is  called  forth  by  the 
nerves,  they  also  are  exercised.  The  oxidation  of  carbon  and  perhaps  of 
nitroo-en  is  also  increased  by  exercise,  so  is  the  elimination  of  water,  as  we 
see  in  the  perspiration  produced,  so  that  the  body  contains  less  water 
after  a  spell  of  work  unless  this  effect  has  been  neutralized  by  the  per- 
son drinking.  In  every  organ  there  is  more  rapid  circulation,  more 
rapid  flow  of  plasma,  as  well  as  more  active  absorption,  that  is  to  say, 
there  is  more  waste  and  quicker  repair.  Thus  the  products  of  action  are 
at  once  removed,  instead  of  accumulating  in  the  organs.  Further,  there 
is  a  greater  escape  of  heat  by  the  evaporation  of  the  increased  perspira- 
tion. We  see,  then,  that  nitrogen  and  carbon  are  required.  If  not  sup- 
plied the  absorption  of  oxygen  and  the  molecular  changes  would  be  re- 
tarded, as  would   also   the  elimination   of  carbon.      What  we   have   said 


EXEKCISE    AND    REST.  95 

applies  to  moderate  exercise,  immoderate  work  may  produce  exhaustion  ; 
moreover,  the  muscles  require  periods  of  rest  in  which  to  store  up  the 
material  which  is  metabolized  during  contraction.  It  would  seem,  too, 
that  oxygen  may  be  stored  up  during  rest.  Both  the  heart  and  the 
lungs  should  be  sound,  in  order  to  secure  a  free  blood-supply  to  the  mus- 
cles, and  the  rapid  interchange  between  oxygen  and  carbon  without  too 
much  fatigue  to  those  organs.  All  this  shows  us  that  under  favorable 
circumstances  moderate  exercise,  especially  such  as  calls  forth  the  ener- 
gies of  large  groups  of  muscles  or  many  organs,  is  one  of  the  best  tonics, 
promoting  nutrition  and  improving  the  health  of  the  body  ;  especially  is 
this  the  case  with  outdoor  exercise.  Sometimes,  however,  we  are  only 
able  to  employ  passive  exercise,  and  in  other  cases  special  gymnastics. 

Often  instead  of  exercise  rest  is  desirable,  or  even  essential,  and  then, 
of  course,  we  have  the  converse  of  some  of  the  effects  described,  but  not 
altogether,  for  rest  again  with  proper  food  promotes  nutrition  by  dimin- 
ishing waste.  During  sleep,  for  instance,  there  is  slackened  destructive 
metamorphosis,  but  repair  is  still  going  on,  and  this  accounts  for  the  res- 
toration of  the  wearied  limbs.  Children  feel  the  want  of  sleep  more 
than  adults,  partly  because  of  their  wonderful  activity,  still  more  because 
growth  is  so  rapidly  proceeding.  But  during  rest  not  only  is  there  this 
diminished  molecular  movement,  but  the  respiration  and  circulation  are 
slower,  and  the  work  of  the  organs  less.  As  an  example  the  heart  beats 
less  in  the  horizontal  position,  on  assuming  which  in  health  a  fall  soon 
takes  place  of  twelve  beats  per  minute,  or  17,280  in  twenty-four  hours  ; 
in  disease  the  fall  may  be  twenty,  thirty,  or  forty  beats  per  minute. 
The  consequences  of  such  a  difference  may  be  traced  throughout  the 
body. 

Exercise  and  rest  may  alike  be  local  or  general,  active  or  passive. 
A  limb,  a  group  of  muscles,  a  single  muscle,  an  organ,  or  other  part  may 
be  subjected  to  the  influence  of  either  agent.  When  absolute  repose 
cannot  be  had,  relative  rest  may  be  procured.  Wlien  the  work  of  an 
organ  is  intermittent,  there  is  a  period  of  repose  between  its  efforts. 
Thus  the  heart  rests  during  the  pause  between  its  contractions,  and  we 
are  able  to  lengthen  that  pause,  while  increasing  the  force  of  the  beat, 
and  in  tliis  way  the  rest  of  the  organ  is  increased  ;  as  we  have  remarked, 
the  recumbent  posture  greatly  lessens  the  work  of  the  heart,  as  it  does 
also  of  the  lungs.  In  respiratory  diseases  we  cannot  stop  breathing,  but 
we  may  regulate  it  by  remedies.  In  chronic  cases,  fuller,  deeper  respira- 
tion takes  place  during  exercise,  which  further  secures  other  benefits, 
such  as  improved  appetite  and  digestion,  increased  oxidation,  and  thereby 
augmented  nutrition.  But  we  more  frequently  need  rest  in  diseases  of 
these  organs,  and  this  is  especially  required  in  acute  cases.  Fever,  of 
course,  compels  repose,  as  does  often  inflammation.  In  h.'emoptysis  the 
first  remedy  is  rest,  and  often  this  is  the  only  remedy  required.     In  in- 


96  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

flammation  of  the  air-passages,  besides  avoiding  irritation  by  securing 
tliat  only  warm  and  perhaps  moist  air  passes  along  them,  we  avoid  the 
irritation  which  is  so  injurious,  and,  as  far  as  we  can,  help  them  to  rest. 
Thus  in  laryngitis  we  impose  silence  as  far  as  we  can,  by  forbidding 
speaking,  that  is,  we  give  all  the  rest  possible  to  the  vocal  organ.  In 
bronchitis  the  same  means  are  of  no  little  assistance.  In  capillary  bron- 
chitis we  endeavor  to  attain  the  same  result  by  an  indirect  method — such 
as  relieving  the  oppressed  heart,  promoting  the  removal  of  secretion  from 
the  tubes,  or  arresting  its  outpour  while  maintaining  the  circulation.  In 
pleurisy,  besides  rest  in  bed,  we  may  bandage  the  chest  or  strap  the  af- 
fected side — a  plan  well  reported  of  in  acute  general  pleurisy,  seen  early, 
as  well  as  when  the  disease  is  limited  in  area  with  little  or  no  effusion. 
In  pleuro-pneumonia  caused  by  a  fractured  rib,  the  benefit  of  fixing  the 
part  is  still  more  manifest,  inasmuch  as  it  prevents  the  repetition  of  the 
injury  which  would  take  place  with  every  movement  of  the  broken  bones. 
In  the  intercurrent  pleurisy  of  phthisis,  and  in  the  short  cough  and 
stitch  so  common  at  the  commencement  of  that  disease,  temporary  rest  is 
also  most  beneficial,  as  it  is  in  slight  attacks  of  haemoptysis  during  the 
progress  of  phthisis,  but  care  should  be  taken  not  to  deprive  the  pa- 
tient too  long  of  the  general  exercise  of  which  he  is  in  need,  or  the  lungs 
of  the  free  and  full  breathing  which  is  so  important.  In  advanced  con- 
sumption cough  and  pain,  of  a  most  distressing  kind,  sometimes  appear 
to  be  caused  by  adhesion  of  the  pleural  layers,  and  may  be  eased  by 
such  rest  as  may  be  secured  by  careful  strapping. 


CHAPTER   Xiy. 
ALCOHOL. 

We  come  now  to  a  thorny  subject,  for  alcohol  has  been  alternately 
abused  and  neglected.  Wine  has  been  used  as  a  medicine  from  the 
earliest  times,  and  its  history  as  a  remedy  shows  a  series  of  oscillations 
almost  as  remarkable  as  those  exhibited  in  the  history  of  depletion.  As- 
clepiades  pandered  to  the  Roman  taste  for  wine,  not  only  by  giving  it  at 
once  after  the  evacuants  he  ordered,  but  prescribing  it  in  excess  sometimes, 
even  to  the  extent  of  intoxication,  under  the  pretence  of  thereby  procuring 
sleep,  while  in  other  cases  he  also  ordered  it  for  the  opposite  purpose. 
Other  charlatans  at  different  times  have  abused  the  use  of  alcohol,  and 
upheld  their  practice  by  equally  inconsistent  dogmas.  Even  able  and 
.thoughtful  physicians  have  sometimes  been  led  away  into  excess  or  in- 
consistency in  their  use  of  this  potent  agent.  It  is  perhaps  curious  to 
note  that  the  most  reckless  prescribers  of  stimulants  have  often  appeared 
to  exhibit  a  touch  of  quackery  in  their  conduct.  Abuse  of  alcohol  has 
naturaWy  largely  alternated  with  excess  in  the  employment  of  depress- 
ants, especially  venesection  ;  but  we  must  leave  these  changes  in  medical 
opinion  and  practice  until  we  come  to  the  similar  epochs  which  have 
marked  the  use  of  bleeding. 

Ts  alcohol  a  nutrient  ?  Can  it  be  regarded  as  a  food  ?  It  has  been 
held  that  this  may  be  the  case,  because  the  excretion  of  carbonic  acid 
and  urea  are  lessened  under  its  use.  But  the  experiments  of  Parkes  and 
Wollowicz  show  that  moderate  quantities  do  not  interfere  with  the 
metamorphoses  of  the  nitrogenous  tissues,  while  it  is,  to  sa^^  the  least, 
doubtful  whether  the  exhalation  of  carbonic  acid  is,  after  all,  decreased. 
Another  reason  has,  however,  been  advanced  for  considering  it  a  nutrient, 
viz.  :  that  inasmuch  as  it  is  very  easily  oxidized, -it  takes  the  place  of  ali- 
mentary material,  which  it  thus  spares,  thereby  permitting  the  accumula- 
tion of  hydrocarbons  in  the  system — that  is  to  say  it  fattens.  In  the 
same  way  it  would  supply  heat,  its  value  for  this  purpose  depending 
upon  its  ready  combustibility;  that  is  to  say,  it  is  preferred  to  other  hy- 
drocarbons, and  therefore  oxidized,  while  they  are  left  unattacked  in  its 
presence,  so  that  it  acts  by  sparing  real  nutrient  material.  But  does  it 
thus  supply  heat  ?  It  is  admitted  on  every  hand  that  only  small  quan- 
7 


98  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

titles  can  do  this,  for  larger  amounts  have  been  distinctly  shown  to  reduce 
the  temperature  of  the  body.  Binz  attributes  this  effect  to  a  paralyzing 
influence  on  the  vaso-motor  nerves,  which  results  in  a  dilatation  of  the 
superficial  vessels,  by  which  more  blood  is  brought  to  the  surface  and 
there  cooled  by  radiation;  at  the  same  time  there  is  a  retardation  of 
molecular  change  by  a  direct  depressing  influence  on  the  cells,  and  of 
course  a  diminution  of  the  heat  which  would  be  liberated  by  cell  oxida- 
tion. It  is,  of  course,  by  no  means  impossible  that  such  opposite  effects 
may  be  produced  by  different  doses,  but  it  may  be  observed  that  we  are 
here  considering  quantities  which  fall  short  of  intoxication,  and  the  line 
which  divides  the  one  effect  from  the  other  seems  to  be  much  narrower 
than  is  generally  supposed. 

In  ordinary  language  a  substance  which,  though  it  may  be  oxidized  in 
minute  quantities,  yet  in  rather  larger  amounts  depresses  the  tempera- 
ture and  retards  the  activity  of  cells  is  scarcely  entitled  to  be  called  a 
food,  especially  when  it  does  not  enter  into  the  composition  of  tissues, 
but  if  it  be  shown  to  promote  indirectly  their  repair  or  to  reduce  their 
waste  it  may  be  perhaps  grouped  conveniently  among  indirect  nutrients. 
It  is  admitted  that,  at  any  rate,  some  of  it  undergoes  change  in  the  body, 
for  when  minute  quantities  only  are  taken  it  can  scarcely  be  traced  pass- 
ing out.  What,  then,  becomes  of  it  ?  Our  information  here  is  rather  de- 
ficient. Out  of  the  body  it  is  easily  converted  into  acetic  acid,  and  some* 
have  supposed  that  such  a  change  may  be  effected  in  the  system  ;  in  that 
case  the  acid  would  unite  with  the  soda  in  the  blood  and  the  salt  thus 
formed  would  become  a  carbonate,  which  would  be  excreted  by  the  kid- 
neys in  the  same  way  as  acetates  are  when  taken  into  the  stomach,  but 
the  effect  woxild  not  be  just  the  same,  for  in  g'iving  acetates  by  the  mouth, 
we  give  the  base  as  well  as  the  acid,  whereas,  in  the  case  supposed,  acetic 
or  carbonic  acid  formed  from  alcohol  would  have  to  obtain  their  alkalies 
from  the  system,  and  by  uniting  with  them  might  thus  increase  instead 
of  diminishing  the  natural  acidity  of  the  secretion.  This  would  account 
for  a  slight  increase  of  acidity  which  was  observed  by  Parkes.  Here, 
however,  it  must  be  observed  that  acetic  acid  has  not  been  detected  in 
the  blood,  nor,  indeed,  have  other  intermediate  products  of  the  combustion 
of  alcohol.  It  has  therefore  been  suggested  that  the  oxidation  is  carried, 
so  to  say,  at  a  single  bound  to  its  ultimate  end,  viz.,  the  production  of 
carbonic  acid  and  water.  In  support  of  this  view  it  is  urged  that  before 
all  the  alcohol  has  escaped  elimination  ceases,  or  at  any  rate  its  presence 
cannot  be  detected. 

It  is  impossible  to  determine  from  the  pulmonary  exhalation  the  pro- 
portion which  may  have  been  oxidized,  for  the  carbonic  acid  is  not  in- 
creased, indeed  nearly  all  experiments  point  to  the  conclusion  that  it  is 
rather  decreased.  Unless,  therefore,  some  other  substance  which  would 
yield  carbonic  acid  is  prevented  from  doing  so,  the  alcohol  cannot  be  con- 


ALCOHOL.  99 

verted  into  that  gas.  The  difficulties  attending  the  investigation  into 
tlie  elimination  by  the  skin  are  very  great  ;  we  turn,  therefore,  to  the  kid- 
neys. When  only  small  quantities  of  alcohol  are  taken  it  can  scarcely 
be  detected  in  the  secretions  when  larger  quantities  are  taken  elimina- 
tion soon  commences  by  the  kidneys,  as  well  as  by  the  skin  and  lungs. 
So  constantly  is  this  the  case  that  the  late  Dr.  Anstie  proposed  to  con- 
sider its  appearance  as  a  measure  of  the  saturation  of  the  system,  or 
rather  as  a  sign  that  as  much  had  been  absorbed  as  could  possibly  be 
oxidized.  He  found  that  about  one  and  one-half  fluid  ounce  always 
caused  its  appearance.  Parkes  and  Wollowicz  obtained  this  same  result  ; 
they  found  in  a  strong,  healthy  man,  accustomed  to  take  alcohol  in  mod- 
eration, when  between  one  ounce  and  two  ounces  were  given  him  some  was 
at  once  thrown  out  unchanged  by  the  kidneys,  and  at  the  same  time  some 
ill-effects  began  to  manifest  themselves,  though  only  in  a  slight  degree. 
The  man  lost  his  appetite,  there  was  slight  but  distinct  narcosis,  increased 
rapidity  in  the  heart's  action,  quite  a  rapid  rise  of  temperature  and  greater 
dilatation  of  the  small  vessels.  The  sphygmograph  confirmed  the  analyses, 
and  these  symptoms  ard  considered  to  mark  the  commencement  of  the 
poisonous  effects.  Here,  then,  we  seem  to  be  approaching  a  reply  to  the 
question,  How  much  can  be  consumed  in  the  body  ?  In  a  strono-  man 
from  one  to  one  and  one-half  fluid  ounce  is  the  limit  ;  it  is  possible  some 
persons  might  oxidize  more,  but  the  probability  would  be  that  a  larger 
number  might  be  unable  to  dispose  of  as  much.  After  that  limit  has 
been  passed  the  kidney  begins  to  throw  it  out,  and  symptoms  of  incon- 
venience or  of  distress  may  be  produced  by  its  presence.  Parkes  made 
his  experiments  on  strong,  healthy  men,  and  the  deductions  he  drew  were 
most  moderate.  We  can  scarcely  go  wrong  in  following  so  judicious  an 
observer,  his  experiments  are  only  likely  to  be  corroborated,  and  until  some 
flaw  in  them  can  be  pointed  out  it  seems  reasonable  to  conclude  that 
about  one  ounce  of  absolute  alcohol  should  be  considered  the  limit  which 
ordinary  men  should  not  pass  if  they  wish  to  avoid  danger.  Now,  that 
ounce  of  alcohol  is  contained  in  about  two  ounces  of  brandy,  or  five 
ounces  of  sherry  or  other  strong  wines,  or  eight  to  ten  ounces  of  weaker 
wines,  such  as  hock  and  claret.  If  we  take  the  outside  quantity  it  would 
only  allow  us  to  increase  these  amounts  by  one-half,  and  then  we  should 
have  arrived  at  the  maximum  which  can  be  disposed  of  by  strong  men. 
Of  course,  in  weakly  or  unhealthy  men  the  figure  should  be  reduced.  In 
women,  also,  on  account  of  the  greater  susceptibility  of  the  nervous  sys- 
tem, as  well  as  for  the  less  doses  they  require  of  all  medicines,  the  amount 
should  be  less.  In  children  the  injurious  effects  of  alcohol  are  more 
rapid  in  appearing  and  more  severe  in  character,  so  that  while  it  is  almost 
universally  allowed  that  they  ought  never  to  partake  of  it  as  a  bevera£;-e, 
it  should  only  be  given  as  a  medicine  with  extreme  precaution. 

There  is  this  to  be  said  about  the  medicinal  use  of  alcohol.     We  give 


100  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

other  remedies  which  are  rapidly  excreted  and  we  often  have  to  give  them 
in  such  quantities  as  may  for  a  time  distress  the  secreting  organ.  This 
may  be  particularly  observed  in  acute  cases,  and  it  may  be  that  to  pro- 
duce certain  effects  we  might  administer  alcohol  in  doses  which  could 
not  be  oxidized.  If  we  give  it  as  an  antipyretic,  we  must  give  enough 
to  reduce  the  temperature,  and  that  is  more  than  the  maximum  which 
healthy  men  can  dispose  of  in  the  system,  and  it  is  not  alleged,  so  far 
as  I  remember,  that  larger  quantities  can  be  oxidized  in  disease.  In 
chroTiic  cases  the  use  of  alcohol  presents  a  very  different  aspect.  Here 
it  approaches  rather  the  dietetic  employment,  and  consequently  the  quan- 
tity which  the  patient  ought  not  to  exceed  should  be  rigidly  kept 
within  the  limit  of  that  which  is  likely  to  be  oxidized  in  the  system.  For 
it  should  not  be  forgotten  that  the  surplus  is  thrown  out  by  the  kidneys, 
not  as  so  much  useless,  inoffensive  matter,  but  these  organs  are  irri- 
tated by  the  alcohol  in  its  passage,  and  thus  disease  is  produced.  This  has 
been  denied,  but  although  we  may  recognize  certain  pathological  changes 
in  the  kidney  as  not  necessarily  induced  by  alcohol,  yet  statistics  still 
show  that  drunkards  are  more  liable  than  others  to  renal  disease,  some 
forms  of  which  seem  to  be  the  consequences  of  alcoholic  excess.  But 
even  this  is  not  the  most  important.  It  is  one  of  the  less,  for  the  alcohol 
in  the  system  undoubtedly  affects  other  tissues,  in  most  of  which  fibroid 
or  fatty  degenerative  changes  are  brought  about  by  its  agency.  Fur- 
ther, these  degenerations,  though  naturally  looked  for  in  drunkards,  often 
appear  in  persons  who  consider  themselves  strictly  moderate.  And  what 
else  should  be  expected  ?  They  habitually  take  only  a  little  more  than 
can  be  disposed  of  in  the  system  ;  the  effect  of  the  surplus  must  usually 
be  present,  just  as  when  an  occasional  excess  is  taken  its  effects  con- 
tinue until  elimination  is  complete.  So  long  as  any  surplus  is  in  the 
svstem  the  spirit  circulates  in  the  blood,  and  the  tissues  are  bathed  in 
a  fluid  containing  it.  And  here  it  is  important  to  note  that  elimination 
is  not  so  rapid  as  some  have  supposed.  Subbotin  found  that  it  was  not 
quite  complete  in  twenty-four  hours  ;  Perrin,  Lallemand,  and  Duroy  ob- 
served it  to  go  on  for  thirty-two  hours  ;  and  Parkes  and  Wollowicz,  after 
a  large  quantity  of  brandy,  detected  it  on  the  fifth  day,  though  exhalation 
by  the  lungs  had  ceased  much  earlier.  This  looks  as  if  it  might  accumu- 
late in  the  body  ;  at  any  rate,  it  proves  that  the  alcohol  may  remain  in 
the  system  a  considerable  time  after  the  period  at  which  it  has  generally 
been  supposed  that  elimination  was  completed,  and  when,  accordingly, 
it  has  not  usually  been  looked  for.  This  may  possibly  help  to  account 
for  some  of  the  effects  produced  on  tffe  tissues.  Some  of  these  effects 
we  proceed  to  note. 

On  the  mucous  memhraiie  it  coagulates  the  albumen  and  corrugates 
the  epithelium  ;  this  it  appears  to  do  by  absorbing  water,  and  we  may 
see  the  effect  in  the  mouth. 


ALCOHOL.  101 

In  the  stomach  it  produces  a  sensation  of  warmth  or  pain,  according 
to  the  degree  of  dilution.  It  stimulates  the  mucous  lining,  and  in  small 
doses  may  thereby  aid  digestion,  but  in  large  quantities,  or  if  not  suf- 
ficiently diluted,  it  impairs  that  process,  for  it  precipitates  peptones  and 
brings  on  congestion  of  the  gastric  mucous  membrane.  When  this  mem- 
brane is  habitually  subjected  to  such  a  congestive  irritant  the  connective 
tissue  between  the  glandules  is  increased  and  causes  their  disappearance, 
bringing  about  the  chronic  "catarrhal  condition  "  of  Dr.  Wilson  Fox. 
It  diffuses  easily  into 

The  IBlood. — Here  it  would  seem  the  chemical  changes  are  partially 
arrested.  More  fat  accumulates,  or  at  any  rate  becomes  visible.  Dr. 
B.  W.  Richardson  says  that  the  blood  is  deficient  in  oxygen  when 
alcohol  is  present.  This  should  diminish  antiseptic  resistance  to  disease. 
Dr.  J.  J.  Ridge,  who  some  time  ago  determined  by  experiment  that  alco- 
hol was  injurious  to  growing  cells,  has  lately  made  a  more  surprising  an- 
nouncement. He  says  he  has  experimentally  determined  that  alcohol, 
which  in  considerable  quantity  is  admitted  to  be  an  antiseptic,  is  in  very 
small  proportions  just  the  opposite,  as  he  found  minute  quantities  pro- 
mote the  decomposition  of  both  mineral  and  vegetable  matter,  bacteria 
flourishing  and  being  propagated  to  a  greater  extent  when  a  little  alco- 
hol was  added.  As  soon  as  the  proportion  of  alcohol  is  less  than  one 
per  cent,  he  found  decomposition  hastened  instead  of  retarded  by  its 
presence. 

The  heart  and  vessels  receive  the  full  force  of  the  stimulus.  At  first 
the  pulse  is  fuller  and  more  frequent  ;  it  is  so  far  a  stimulant  according 
to  the  general  notion,  and  this  is  confirmed  by  the  sphygmograph.  It 
quickens  the  systole  and  shortens  the  diastole  or  the  period  of  repose, 
Parkes  found  that  brandy  or  wine  alike  augmented  the  rapidity  of  the 
pulse  about,  thirteen  per  cent.,  at  the  same  time  increasing  the  force  of 
the  beat.  The  period  of  rest  was  shortened,  so  that  the  heart  had  more 
work  and  less  repose.  Now,  such  a  stimulus  as  this  would  seem  in  one 
way  to  lessen  the  nutrition  of  the  organ  by  an  undue  interference  with 
its  natural  balance  of  exercise  and  rest  ;  for  it  is  difficult  to  see  how  ex- 
cessive wear  is  to  be  compensated  during  diminished  repair.  The  effect 
on  the  heart  may  be  compared  to  that  on  the  voluntary  muscles,  which 
alcohol  certainly  weakens,  while  it  certainly  interferes  with  their  co-or- 
dinating power — doubtless  through  the  nervous  system.  The  arteries 
dilate  more  easily  before  the  fiercer  flow  of  the  blood-stream  as  it  is  im- 
pelled by  the  excited  heart,  and  the  superficial  vessels  in  their  turn  also  di- 
late more  fully,  hence  the  familiar  flushing  of  the  skin.  When  this  flush- 
ing becomes  habitual  the  vessels  become  permanently  dilated,  and  thus 
fix  the  mark  of  the  evil  habit  upon  the  person  in  the  turgescence  of 
the  capillaries  and  the  altered  condition  of  the  skin,  which  gives  to  the 
individual  the  appearance  of  premature  old  age.      Perhaps  this  yielding 


102  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

of  the  vascular  system  may  serve  as  a  kind  of  safety-valve  ;  for  other- 
wise the  strong  wave  might  rupture  the  vessels,  or  else,  the  force  acting 
in  the  other  direction,  the  heart  might  not  be  emptied  by  the  contraction, 
and  thus  other  inconveniences  would  arise.  This  would  seem  to  indicate 
that  when  the  arteries  are  rigid  alcohol  might  be  more  dangerous,  unless 
for  some  reason  the  heart  did  not  react  as  usual  under  its  influence. 

J^ervous  System. — Perhaps  the  phenomena  produced  on  the  vascular 
system  may  be  the  indirect  effects  of  the  action  on  nervous  tissue. 
Anstie  and  others  have  attributed  them  to  the  influence  on  the  sympa- 
thetic, but  others  consider  the  vagus  and  the  heart  to  be  involved.  On 
the  cerebrum  the  first  effect  is  exciting  ;  alcohol  certainly  increases  the 
rapidity  of  the  flow  of  ideas,  but  by  no  means  the  power  of  controlling 
or  directing  them.  This  faculty  is,  in  fact,  diminished  ;  close,  concentrated 
attention  is  rendered  difficult  or  impossible  ;  very  soon,  however,  a  nar- 
cotic or  anaesthetic  effect  comes  on,  and  then  the  rapidity  of  ideas  or  im- 
pressions is  naturally  lessened.  Even  when,  as  sometimes,  the  imagination 
seems  to  be  stimulated,  it  becomes  uncontrollable.  As  to  the  special 
senses,  they  scarcely  seem  to  pass  through  the  stage  of  excitement,  but 
under  quite  small  quantities  their  acuteness  or  their  accuracy  is  lessened. 
From  this  deadening  of  the  senses,  as  well  as  the  muscular  power,  it  would 
seem  to  interfere  with  the  movements  of  nervous  currents,  and  it  has 
been  conjectured  that  it  may  do  this  by  entering  into  a  temporary  com- 
bination with  nervous  tissue.  But  can  it  do  this  ?  and  if  so,  would  it  be 
a  nutrient  or  only  a  poison  ?  As  to  the  first  question  we  are  in  doubt. 
We  know  that  considerable  quantities  have  been  found  saturating,  so  to 
say,  the  brain,  or  bathing  nervous  tissue,  but  this  certainly  does  not  neces- 
sitate a  combination,  and  out  of  the  body  the  tissue  may  be  steeped  in 
the  spirit,  which  hardens  and  preserves  it  but  does  not  appear  to  combine 
with  it.  With  regard  to  the  second  question,  it  can  only  be  regarded 
as  a  nutrient  if  it  combine  with  the  tissue  as  a  necessary  ingredient,  or 
as  something  assisting  its  formation  or  disintegration  by  the  usual  steps. 
If,  by  any  combination  it  may  be  supposed  to  form,  it  hindered  the  usual 
constructive  and  destructive  changes,  and  at  the  same  time  impaired  or 
prevented  its  function,  it  would  have  no  title  for  such  reasons  to  be 
called  nutrient,  though  it  might  fairly  be  termed  poisonous. 

The  Liver. — The  degenerative  changes  produced  on  this  organ  are 
generally  well  known,  but  how  much  alcohol  may  be  taken  without  setting 
them  up  we  have  no  means  of  determining  with  any  degree  of  certainty. 

Mespiratory  System. — The  muscles  or  nerves  of  respiration  may  be 
impaired  or  paralyzed,  and  death  sometimes  occurs  in  consequence.  The 
carbonic  acid  and  the  watery  vapor  exhaled  seems  to  be  lessened,  though 
different  results  have  been  observed  in  some  of  the  experiments.  Dr.  E. 
Smith  observed  different  effects  with  different  kinds  of  spirits.  It  may 
be  supposed  that  some  variation  might  occur  from  the  influence  on  diges- 


ALCOHOL.  103 

tion  or  circulation,  or  from  other  circumstances.  There  is  room,  perhaps, 
for  further  investigation,  but  it  seems  pretty  certain  that  if  not  much 
lessened  the  carbonic  acid  is  certainly  not  usually  increased.  The  bron- 
chial mucous  membrane,  and  perhaps  also  the  pulmonary  tissue,  must  be 
injuriously  affected  by  habitual  excess  of  alcohol,  and  chronic  bronchitis 
and  lobar  emphysema  are  among  the  penalties  of  heavy  drinking. 

Cutaneous  System. — It  is  often  said  that  alcohol  is  a  sudorific,  and  hot 
grog  is  a  popular  dose,  but  the  effect  of  the  hot  water  should  not  be  over- 
looked. Dr.  Edward  Smith  thought  alcohol  lessened  the  amount  of  per- 
spiration, but  Weyrick  found  a  large  increase  after  all  alcoholic  beverages. 
No  doubt  the  dilatation  of  the  cutaneous  vessels  produced  by  alcohol 
tends  to  promote  perspiration,  but  the  effect  is  not  such  that  it  can  be 
relied  on  as  a  diaphoretic  ;  indeed,  when  taken  cold,  it  is  much  more 
likely  to  prove  diuretic.  As  to  the  sudorific  influence  of  hot  grog,  tea  or 
any  other  hot  beverage  is  equally  efficacious  and  less  likely  to  be  injurious, 
while  a  dose  of  sweet  spirits  of  nitre  in  hot  water  is  a  domestic  diapho- 
retic of  much  greater  value. 

Temperature. — The  effect  on  temperature  is  less  than  might  have  been 
supposed  from  the  vascular  phenomena.  Quite  small  doses  do  not  affect 
the  clinical  thermometer.  Experimenting  on  two  healthy  men,  who 
were  accustomed  to  take  beer,  and  occasionally  spirits,  but  who  were 
strictly  temperate,  Parkes  found  neither  a  rise  nor  fall ;  Mainzer  ob- 
served a  slight  fall  in  one  instance  and  none  in  another  ;  Obernier  and 
Fokker  also  obtained  no  certain  conclusions.  But  when  larger  doses  are 
given  there  seems  no  doubt  that  the  usual  effect  is  to  cause  a  fall.  Binz, 
Ruge,  Cuny-Bouvier,  Richardson,  Ringer,  and  Richards  all  seem  to  have 
met  with  this  result.  Lewis,  Wood,  and  Reichert  consider  that  the  pro- 
duction and  dissipation  of  heat  are  both  increased,  Parkes  found  a  dif- 
ference in  respect  to  the  food,  no  effect  being  perceived  when  the  alcohol 
was  taken  with  a  meal,  but  taken  fasting  a  fall  occurred.  Ringer  found 
in  a  boy,  aged  ten  years,  who  had  never  in  his  life  before  tasted  alcohol, 
a  constant  and  decided  reduction  of  temperature.  We  may,  perhaps, 
then  conclude  that  in  health  a  moderate  fall  usually  follows  the  dose  of 
alcohol  ;  but  no  doubt  this  is  much  less,  if  at  all  perceptible  in  those  ac- 
customed to  its  use.  In  old  topers  the  temperature  is  unaffected  even  bv 
large  quantities.  Drs.  Ringer  and  Richards  once  gave  to  an  habitual 
drunkard  twelve  ounces  of  brandy  in  a  single  dose,  which  made  him  dead- 
drunk,  but  without  the  smallest  reduction  of  the  temperature. 

We  come  now  to  the  therapeutic  uses  of  alcohol.  Twenty-five  years 
ago  it  was  prescribed  by  almost  every  house-surgeon,  so  freely  as  to 
seem  almost  routine  practice,  just  as  their  predecessors,  twenty-five  years 
before  them,  had  employed  bleeding  and  depressants.  At  present  a  con- 
siderable reaction  has  occurred,  and  alcohol  is  much  more  cautiously  pre- 
scribed.    It  is  said  to  be  stimukmt  ;  this  term  is  indeed  applied  generally 


104  THERAPEUTICS    OF    THE    RESPIRATORY   PASSAGES. 

to  all  intoxicating  liquors,  but  we  ought  not  to  forget  that  it  may  just 
as  properly  be  termed  narcotic,  for  after  the  exhilarating  influence  it 
produces  drowsiness  and,  in  sufficient  doses,  coma.  It  has  also  been  called 
anodyne  and  a^imsthetic,  and  undoubtedly  it  lessens  the  consciousness  of 
pain  by  deadening  the  perceptive  power.  Does  it  promote  nutrition  if  the 
amount  given  be  within  the  limit  which  can  be  oxidized  Avithin  the  sys- 
tem ?  or  does  it,  by  hindering  waste,  merely  cause  an  accumulation  of 
useless  effete  material  ?  Opinions  still  differ  on  these  points,  but  it  seems 
clear  that  it  can  only  be  a  nutrient  indirectly,  and  to  a  very  slight  degree. 
Even  so  far  as  it  is  consumed,  if  it  depress  function,  as  it  seems  difficult  to 
deny,  would  it  not  favor  degeneration  ?  If  so,  that  would  surely  counter- 
balance the  assumed  advantage  of  its  liberating  force.  To  check  oxidation 
is  not  necessarily  to  promote  nutrition  ;  to  economize  blood,  or  even  tissue, 
may  not  be  so  desirable  as  to  quicken  their  renewal.  It  has  sometimes 
been  given  rather  freely  as  an  antipyretic,  and  we  must  admit  that  in 
the  febrile  state  the  effect  is  greater  in  this  direction  than  in  health. 
Binz  and  Bouvier  produced  septic  fever  in  animals,  and  then  reduced 
their  temperature  by  alcohol.  On  the  other  hand,  one  of  the  men  who 
was  taking  considerable  doses  in  Dr.  Parkes'  experiments  took  cold,  and 
his  temperature  rose  in  spite  of  the  alcohol.  Others  have  found  that  it 
cannot  be  relied  upon  to  abate  ordinary  febrile  excitement,  though  there 
are  many  records  in  which  it  has  seemed  to  moderate  septic  fever.  It 
would  seem  to  act  more  powerfully  on  animals  than  on  men,  but  perhaps 
this  may  be  due  to  the  influence  of  habit.  We  must  conclude  that  a 
high  temperature  is  not  necessarily  a  contra-indication,  though  the  pres- 
ence of  arterial  excitement  and  sthenic  inflammation  may  be  so  regarded. 
Binz  showed  that  it  did  not  lower  the  temperature  through  the  nervous 
system,  so  that  the  effect  is  probably  due  to  its  retarding  metabolism. 
He  gives  it  in  order  that  it  may  be  consumed,  and  so  spare  the  tissues 
and  supply  animal  heat.  With  such  a  view  the  amount  administered 
surely  ought  not  to  exceed  that  which  can  thus  be  utilized,  and  yet  it  is 
too  common  for  his  followers  to  give  much  more.  He  says  that  small 
doses  do  not  really  stimulate,  and  compares  them  to  small  quantities  of 
fuel  laid  upon  a  fire  to  prevent  it  going  out.  Exception  might  be  taken 
to  such  comparisons,  many  of  which  have  been  introduced  into  discussions 
on  this  subject,  but  few,  if  any  of  which  appear  to  me  to  have  shed  much 
light  upon  it.  I  have,  therefore,  in  this  chapter  rigidly  confined  myself 
to  a  statement  of  some  of  the  most  important  facts  and  the  conclusions 
which  seem  to  me  to  be  fairly  deduced  from  them.  To  obtain  any  con- 
siderable antipyretic  effect  it  is  necessary  to  employ  large  doses,  so  large 
as  to  be  often  dangerous,  and  therefore  great  caution  is  incumbent  on 
all  who  use  it  for  this  purpose,  and  as  the  results  are  too  slight  in  or- 
dinary pyrexia,  it  ought  not  to  be  resorted  to  unless  other  indications 
than  fever  are  present. 


ALCOHOL.  105 

As  an  illustration  of  its  stimulant  action,  its  effect  in  rousing  the 
heart  and  circulation  in  syncope  is  familiar  to  all.  It  would  probably 
have  been  much  less  familiar  but  for  the  fact  that  some  form  of  wine  or 
spirit  is  present  in  almost  all  households,  and  therefore  in  a  case  of  faint- 
ing it  is  the  most  ready  remedy.  As  an  anaesthetic  or  anodyne  it  is 
sometimes  resorted  to  in  neuralgia  and  other  painful  affections,  but  the 
practice  is  dangerous  whenever  the  pain  is  recurrent,  inasmuch  as  it  is 
likely  to  lead  to  a  too  frequent  repetition,  and  so  may  induce  habits  of 
intemperance.  This  danger  ought  never  to  be  forgotten  in  chronic  dis- 
eases, especially  as  in  them  it  is  often  administered  in  the  shape  of  a 
beverage,  and  it  is  easy  to  understand  that  when  it  seems  to  afford  relief 
it  may  be  resorted  to  more  frequently  than  at  first  intended,  especially 
by  those  who  may  not  be  aware  of  the  ease  with  which  it  becomes  a 
snare.  The  more  caution  is  required,  inasmuch  as,  after  all,  we  have  more 
potent  remedies  of  this  kind  which  are  not  dangerous  in  this  direction  ; 
and  if  we  had  not,  it  would  be  better  to  endure  the  disease  or  to  face 
death  than  to  become  the  victim  of  intemperance. 

Among  acute  diseases,  pneumonia  has  been  largely  treated  with  al- 
cohol. Indeed,  this  disease  has  been  made  the  battle-ground  between 
its  advocates  and  opponents,  just  as  it  was  in  reference  to  bleeding. 
Now,  however,  it  is  generally  admitted  that  simple  pneumonia  in  healthy 
persons  tends  toward  recovery,  and  therefore  such  a  remedy  should 
only  be  employed  to  meet  certain  conditions.  As  in  all  acute  diseases 
with  such  a  tendency,  few  would  now  resort  to  it  during  the  early  pro- 
gressive stage,  but  when  only  the  results  remain  it  is  often  employed 
with  a  view  to  restraining  waste,  or  to  being  itself,  as  some  still  suppose, 
a  substitute  for  food.  In  such  cases  it  is  generally  combined  with  milk, 
or  alternated  with  that  and  other  aliments,  and  possibly  much  of  its  in- 
fluence may  be  due  to  its  stimulating  digestion,  and  facilitating  the  as- 
similation of  the  accompanying  food.  Wood,  who  is  by  no  means  averse 
to  the  use  of  alcohol,  confines  its  use  in  acute  pneumonia  to  cases  "  when 
so  much  consolidation  has  occurred  as  to  render  it  doubtful  whether  the 
exuded  matter  can  be  removed,"  and  then  he  thinks  the  demand  for  it 
may  be  "  very  great  as  a  food  and  as  an  aider  of  digestion,  and  some- 
times as  a  stimulant." 

In  phthisis,  as  a  narcotic  possessing  some  antipyretic  action,  it  is 
sometimes  given  at  night,  but  it  should  be  combined  with  some  form  of 
food.  Under  its  influence  sometimes  the  patient  sleeps  better  and  the 
night-sweats  diminish  ;  for  this  purpose  but  small  doses  are  required,  and 
perhaps  they  are  chiefly  useful  in  promoting  digestion;  and  the  same  may 
be  said  as  to  very  small  doses  given  early  in  the  morning  in  conjunction 
with  aliment,  such  as  the  popular  rum  and  milk.  Whatever  spirit  be 
employed  for  this  purpose,  for  others  are  just  as  efficient,  and  to  many 
more  pleasant  than  rum,  the  dose  should  only  be  enough  to  assist  diges- 


106  THERAPEUTICS    OF    THE    RESPIEATORY    PASSAGES. 

tion,  and  perhaps  other  aids  to  this  process  would  be  generally  prefer- 
able. In  chronic  phthisis  alcohol  is  sometimes  prescribed  at  the  same 
time  as  cod-liver  oil,  and  by  some  under  the  impression  that  it  will  assist 
its  digestion  ;  but  from  what  has  preceded  it  would  appear  that  ether 
would  be  a  more  efficient  adjunct.  In  the  sleeplessness  of  old  age  a  small 
dose  at  night  often  procures  relief,  and  the  night-cap,  as  this  is  called, 
is  therefore  popular  ;  but  here  again  it  should  not  be  given  without  food, 
and  ver}^  often  nutriment  alone  will  be  equally,  or  even  more  effectual 
for  the  immediate  purpose,  and  then,  as  every  one  will  admit,  should  cer- 
tainly be  preferred.  The  small  dose  of  alcohol  probably  acts  by  stimu- 
lating the  stomach,  as  well  as  by  exciting  the  feeble  circulation  ;  but  in 
view  of  this  latter  action  it  is  important  that  the  arteries  be  sound. 
Where  this  is  the  case,  stimulants  of  any  kind  may  be  given  earlier  in 
old  age  and  feeble  persons  than  in  robust  adults. 

The  importance  of  giving  food  with  the  alcohol  has  several  times  been 
mentioned,  and  it  is  to  be  feared  that  much  injury  arises  from  the 
neglect  of  this  precaution.  Even  in  extreme  prostration  small  quantities 
of  milk  and  alcohol  can  be  taken  at  frequent  intervals,  but  unless  strict 
injunctions  be  given  to  the  attendants  they  are  apt  to  separate  the  one 
from  the  other,  and  the  result  may  be  that  while  the  patient  gets  the 
stimulus  the  due  quantity  of  aliment  is  not  taken.  The  wine  or  spirit  is 
trusted  to  ;  the  heart  responds  for  a  time,  but  is  not  properly  fed,  and 
the  consequences  are  necessarily  disastrous.  Patients  who  are  strong 
enough  to  observe  their  regular  meal-times  should  generally  do  so,  as  the 
stomach  seems,  from  the  force  of  habit,  to  work  more  easily  in  this  way, 
and  whatever  stimulant  be  prescribed  should  be  given  with  the  food, 
unless  urgent  reasons  exist  for  administering  it  at  other  times.  Al- 
together, then,  whether  in  acute  or  chronic  disease,  whenever  stimulants 
are  administered,  it  is  an  excellent  rule  to  give  them  only  in  conjunction 
with  some  form  of  food. 


CHAPTER    XY. 
DENUTEIENTS. 

Remedies  which  hasten  destructive  changes  next  demand  attention. 
We  have  already  seen  that  vpater  and  exercise  may  do  this.  Neverthe- 
less, they  are  indirectly  promoters  of  construction  unless  taken  in  excess. 
It  may  further  be  said  that  some  other  agents  more  distinctly  destructive 
may  also  be  employed  in  such  a  manner  as  to  become  indirect  nutrients — 
e.g.,  fasting,  which  arrests  the  supply jo^'O  tern.,  and  low  diet,  which  restricts 
it,  give  time  for  the  removal  of  waste,  and  perhaps  at  the  same  time 
arrest,  or  at  least  retard  metabolism  ;  but  when  a  new  supply  arrives  its 
stimulus  seems  to  provoke  increased  rapidity  of  construction,  so  that 
the  loss  is  soon  made  up  out  of  the  fresh  abundance.  In  the  same  way 
quickening  excretion  by  evacuants,  when  carried  far,  causes  waste;  but  a 
slight  degree  of  the  same  process  only  stimulates  to  increased  renewal. 
Further,  the  removal  of  the  completely  prepared  nutrient  fluid  may  act  in 
a  similar  manner,  e.g.,  sudden  hemorrhage  takes  away  the  nutrient  fluid  ; 
but  we  see  in  accidents  how  rapidly  loss  of  blood  is  made  up  for  in 
liealthy  persons,  and  so  it  often  is  in  disease.  That  a  moderate  loss  of 
blood  may  really  stimulate  to  increased  nutrition  is  a  familiar  fact  to 
many  farmers,  who  when  they  find  their  cattle  slow  to  fatten  will  bleed 
them.  It  may  be,  then,  that  denutrients  stimulate  construction,  but  they 
are  usually  spoken  of,  in  consequence  of  their  more  direct  effects,  as 
weakening,  depressing,  lowering,  etc.  For  the  present,  then,  we  have  to 
consider  them  under  this  aspect,  whether  they  act  by  removing  nutrient 
material  or  by  quickening  destructive  metamorphoses,  or  both. 

One  of  the  most  important  groups  is 

Antiphlogistics, 

So  named  because  they  are  employed  in  inflammation  (avri,  against, 
<^Aoyow,  I  inflame).  This  word,  from  the  Latin  inflammatio,  itself  derived 
from  the  verb  inflammo,  I  set  on  fire,  appears  in  almost  the  same  form  in 
all  the  languages  of  Latin  origin.  The  German  entzilndung  has  a  similar 
meaning,  which  is  also  found  in  other  Teutonic  tongues.  The  idea  of 
kindling  or  burning  is  also  found  in  the  words  by  which  inflammation  is 


108  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

expressed  in  Hebrew,  Sanscrit,  Arabic,  and  perhaps  other  languages. 
Our  word  "fever,"  Latin  febris,  ivomfcrveo,  I  am  hot,  is  also  as  widely 
distributed,  for  not  only  is  it  found  in  all  the  Latin  languages,  but 
the  German  fieber  shows  that  it  has  spread  to  the  Teutonic.  The  syno- 
nym, pyrexia,  from  the  Greek  Trup,  fire,  has  a  similar  origin,  and  phleg. 
mon,  (^Aeyo),  and  phlogosis,  once  in  common  use,  expressed  the  same 
notion  (<^Ao^,  a  flame).  All  these  words  have  to  do  with  the  most  strik- 
ing symptom  of  the  process,  and  show  that  the  preternatural  heat  or 
sensation  of  burning  has  in  all  ages  attracted  attention.  Charaka  divided 
remedies  into  those  which  increased  or  diminished  internal  fire,  while 
Susruta  divided  them  into  those  which  increase  the  strength  by  evacuat- 
ing bad  humors,  and  those  which  lower  the  exalted  action  of  the  humors. 
So  extended,  too,  has  been  the  idea  of  febrile  action,  that  Hindu  physi- 
cians say  "  that  man  is  both  born  and  dies  in  fevers  (juvara)  ; "  while  the 
Chinese  do  not  seem  to  separate  inflammation  from  fever,  though  they  do 
distinguish  several  kinds  of  fever. 

The  antiphlogistic  diet  and  regimen  has  always  implied  a  restriction 
of  food  and  the  imposition  of  rest.  Everything  supposed  to  increase 
heat  has  been  banished,  and  the  patient  placed  on  the  mildest  farinaceous 
fluid  food,  and  very  little  of  it  ;  the  beverages,  also,  have  been  simple 
diluents.  At  times  such  restrictions  have  been  carried  too  far,  and  al- 
though judicious  physicians  have  generally  been  found  to  inculcate  the 
necessity  of  tempering  the  remedies  to  the  patient,  and  even  to  the  cause 
of  the  disease,  there  has  very  often  been  a  danger  of  too  strict  adherence 
to  the  notion  of  combating  inflammation  by  lowering  measures.  Of 
this  a  striking  example  was  afforded  when  French  physicians  not  only 
imposed  their  absolute  diet,  that  is  to  say,  denied  their  patients  every- 
thing but  pure  water,  but  also  practised  bleeding  and  administered  evacu- 
ants.  But  England  was  not  much  behind,  for  although  there  were  always 
opponents  to  extremes  of  this  kind,  the  general  practice  of  the  last 
generation  was  not  inaptly  described  by  the  good  and  learned  Dr.  John 
Lettsom,  in  his  rhyming  pun  on  his  own  name. 

"  When  patients  do  to  me  apply, 

I  physics  [=  purges],  bleeds,  and  sweats  'em  ; 
If  after  that  they  choose  to  die, 

What's  th<at  to  me  ?     I  lets  'em  [I.  Lettsom]." 

Rest  as  an  antiphlogistic  agent  ought  to  be  both  physical  and  mental, 
besides  which  local  rest  may  be  special.  The  object  is  to  abate  vascular 
action,  to  prevent  waste  of  vital  power,  and  avoid  exhaustion.  In  severe 
cases,  rest  in  bed  is  necessary,  and  it  is  always  the  best  form  of  repose, 
for  it  usually  tranquillizes  the  patient,  prevents  chills,  and  keeps  him 
warm,  i.e.,  prevents  excessive  expenditure  of  animal  heat,  though  some- 
times we  are  glad  to  provide  for  the  escape  of  its  extra  production.     In 


DENUTRIENTS.  109 

severe  cases  of  extensive  inflammation,  or  of  febrile  excitement,  loss  of 
appetite  settles  the  question  of  the  amount  of  food,  but  sometimes  solids 
can  be  taken,  and  need  not  always  be  forbidden  ;  indeed,  in  some  inflam- 
matory affections  of  the  respiratory  organs,  easily  digested  solids  may  be 
given  all  through. 

BLEEDING. 

The  most  potent  antiphlogistic  is  depletion.  In  all  ages  some  form 
of  blood-letting,  local  or  general,  has  been  more  or  less  employed,  and 
though  now  so  largely  in  abeyance,  is  still  maintained  by  many  to  be  a 
sure  means  of  relieving  pain,  modifying  disease,  and  even  saving  life. 
Still  there  have  been  remarkable  changes  in  medical  opinion.  At  one 
time  excessive  depletion  has  been  practised,  such  as  that  of  the  last  two 
centuries,  so  pungently  ridiculed  by  Moliere  and  Le  Sage.  At  another 
time  the  natural  reaction  has  led  to  an  opposite  extreme,  as  during  the 
period  of  the  Brunonian  triumph  and  the  still  more  recent  attempt  to 
banish  venesection  in  favor  of  alcohol.  Hippocrates,  as  well  as  his  pre- 
decessors and  disciples,  bled,  but  he  also  fed,  and  much  disapproved  of 
indiscriminate  starvation.  He  practised  phlebotomy  as  well  as  cupping 
and  scarification  ;  indeed,  he  mentions  one  case  in  which  he  bled  first  in 
one  arm,  then  in  the  other,  till  the  patient,  he  says,  had  scarcely  any 
blood  left  in  his  body,  but  he  was  perfectly  cured.  Erasistratus,  accord- 
ing to  Galen,  interdicted  venesection,  but  others  writers  say  he  did  not 
absolutely  forbid^ it,  but  used  it  less  than  his  contemporaries,  and  dis- 
trusted it,  relying  rather  on  diet,  regimen,  and  topical  applications,  in 
which  he  was  directly  opposed  to  his  contemporary  Herophilus.  Ascle- 
piades  was  not  particularly  averse  to  bleeding,  althougl^he  rather  trusted 
diet  and  regimen,  and  cold  water  both  externally  and  internally.  He  is 
believed  to  have  invented  the  shower-bath.  He  prescribed  with  great 
freedom  wane,  and  hence  was  very  popular  with  the  Romans  ;  and  he 
said  that  pleurisy  bore  venesection  on  the  Hellespont,  but  not  at  Rome. 
His  pupil,  Themison,  was  the  founder  of  the  Methodists,  and,  like  his 
model,  first  weakened  his  patients  by  starvation,  and  then  gave  them- 
wine  as  freely  ;  for  which  practice  he  incurred  the  keen  satire  of  Juvenal. 

"  Quot  Themison  regros  autumno  occiderat  mio  "  (Sat.  10,  v.  221). 

"  How  many  sick  in  one  short  autnmn  fell, 
Let  Themison,  their  ruthless  slayer,  tell." 

Celsus  employed  bleeding  more  generally,  but  in  less  quantities  than 
Hippocrates,  and  expressing  a  fear  lest  copious  venesection  should  ex- 
haust his  patient,  recommended  small  bleedings  repeated  more  fre- 
quently. He  also  used  cupping,  and  still  more  scarifying  ;  at  the  same 
time  he  prescribed   abstinence  at  the  commencement  of  the  disease,  but 


110  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

later  on  he  cautiously  returned  to  a  generous  diet.  Galen  raised  a  re- 
action in  favor  of  the  doctrines  of  Hippocrates.  When  he  appeared, 
about  the  year  130,  there  was  a  great  rivalry  between  the  Dogmatists, 
Empyrics,  and  Methodists,  the  last  of  which  were  in  the  ascendency. 
It  has  been  supposed  that  Galen  began  as  an  eclectic,  as  he  professed 
to  follow  no  one  authority,  but  he  very  soon  became  the  greatest  ex- 
ponent of  Hippocrates,  whose  authority  he  placed  higher  than  any.  He 
revived  the  Hippocratic  system  almost  in  its  original  state,  but  he  still 
dallied  a  little  with  the  useless  notions  of  the  Dogmatists,  who  foolishly 
repudiated  that  patient  observation  on  which  the  sage  of  Cos  founded 
all  his  doctrines.  The  authority  of  Galen  overshadowed,  if  it  did  not 
amalgamate,  the  various  sects  in  medicine,  so  that  the  unity  of  the  pro- 
fession may  almost  be  dated  from  his  time.  After  him  came  the  Dark 
Ages,  during  which  little  advance  was  made,  but  from  the  glimpses  we 
get  of  the  few  men  of  genius  who  lived  in  those  long  centuries  we  find 
the  same  practice  of  bleeding  prevalent.  Galen  seems  to  have  been  the 
first  who  performed  arteriotomy  in  the  manner  which  is  now  practised. 
This  he  did  on  himself,  by  opening  the  artery  between  his  own  finger 
and  thumb  when  suffering  severe  pain  in  the  region  of  the  diaphragm, 
which  was  relieved  after  the  loss  of  about  a  pint  of  blood.  Before  his 
time  the  operation  was  performed  in  a  different  manner.  Oribasius 
greatly  favored  scarification  by  incisions,  a  much  more  formidable  oper- 
ation than  that  to  which  we  now  apply  the  word,  a  scalpel  being  used 
to  make  deep  incisions  after  ligature  of  the  limb  and  beating  it  with 
reeds  to  make  it  swell.  He  practised  venesection  as  well.  He  was  a  man 
of  considerable  genius,  and  greatly  distinguished  for  his  therapeutical  ac- 
quirements. Aetius,  the  great  surgeon  and  advocate  of  the  actual  cau- 
tery, followed  the  same  practice  ;  and  Alexander,  who  flourished  about 
the  middle  of  the  sixth  century,  and  who  possessed  more  originality 
than  either  of  the  last  named,  bled  in  fevers,  in  coughs,  in  pleurisy,  in 
mumps,  and  says  that  it  is  the  chief  remedy  in  quinsy,  but  should  not 
be  carried  to  syncope.  He  is  the  earliest  writer  who  mentions  a  stone 
being  coughed  up  from  the  lungs  after  causing  the  symptoms  of  con- 
sumption. He  also  recommended  venesection  in  the  paroxysms  of  stone. 
Paulus  of  ^gina  bled  from  the  jugular  vein  in  diseases  of  the  eyes,  a 
practice  not  quite  new  with  him,  as  Alexander  had  previously  opened 
this  vein  for  quinsy.  Paulus  describes  the  various  modes  of  performing 
arteriotomy  in  his  day,  just  as  he  does  other  more  formidable  surgical 
operations,  his  writings  treating  very  fully  of  all  the  operations  known 
at  the  time,  among  which,  as  connected  with  our  subject,  we  may  men- 
tion tracheotomy,  which  he  recommends  under  various  circumstances, 
and  gives  directions  for  its  performance, 

Rhazes,  one  of  the  most  illustrious  of  Arabian  writers,  at  the  close  of 
the  ninth  and  beginning  of  the  tenth  century,  practised  bleeding  quite 


DENUTKIENTS.  Ill 

as  freely.  In  one  case  we  find  him  opening  the  basilic  and  saphena 
veins  at  once,  taking  from  each  half  a  pound,  and  in  three  hours'  time 
loosening  the  bandage  and  removing  a  similar  quantity  ;  and  as  soon  as 
the  patient  had  taken  some  nourishment,  opening  the  saphena  the  third 
time,  and  after  another  interval  of  three  hours  removing  a  fifth  half- 
pound.  Avicenna,  born  980,  died  1036,  followed  Galen's  practice. 
Albucasis  describes  various  modes  of  bleeding  and  the  numerous  in- 
struments employed  ;  he  carried  venesection  to  its  utmost  extent  at  the 
commencement  of  small-pox,  and  to  him  belongs  the  credit  of  having 
first  employed  a  cold  regimen  in  that  disease.  We  must  pass  over  the 
other  Arabians,  whose  works  are  mostly  transcripts  of  the  Greek  writers, 
although  they  contain  many  interesting  additions,  especially  in  reference 
to  pharmacy  and  chemistry,  to  which  they  devoted  so  much  attention. 
From  them  may  be  said  to  date  the  origin  of  pharmacopoeias,  and  they 
seem  to  have  discovered  some  of  our  most  useful  purgatives. 

The  school  of  Salernum  rose  from  the  darkness  which  surrounded 
the  Christian  world  at  a  time  when  clerical  imposture  and  ignorance  was 
only  matched  by  the  prevalent  superstitions.  This  school,  which  origi- 
nated in  a  Benedictine  monastery,  studied  and  translated  both  Greek  and 
Arabian  writings,  and  chiefly  followed  the  teachings  of  Galen. 

Passing  on  to  the  sixteenth  century  we  see  how  prevalent  bleeding 
must  have  been  from  the  remarkable  controversy  which  ensued  when 
Brissot  '  proposed  to  restore  the  method  of  bleeding  on  the  side  of  the 
disease  in  pleurisy,  as  it  had  been  practised  by  Hippocrates  and  Galen, 
but  which  seems  to  have  been  reversed  by  the  Arabians.  Denys,  then 
physician  to  the  King  of  Portugal,  opposed  the  innovator,  and  the  dis- 
pute among  physicians  became  so  keen  that  it  was  brought  before  the 
University  of  Salamanca,  and  Brissot  forbidden  to  practise  until  the 
question  was  decided.  After  a  long  hearing,  the  University  pronounced 
that  Brissot  was  right,  and  in  strict  accordance  with  Hippocrates  and 
Galen  ;  but  the  partisans  of  Denys  appealed  to  the  Emperor  Charles  V., 
denouncing  Brissot's  method  as  impious,  heretical,  and  even  Lutheran  ! 
Botallus  (Leonard)  flourished  only  half  a  century  later,  but  during  that 
time  venesection  had  been  becoming  less  employed,  and  indeed  seems  to 
have  fallen  nearly  into  disuse,  but  he  produced  quite  a  revival  in  its 
favor  by  his  work  on  the  subject.^  He  relates  one  case  in  which  he 
bled  the  patient  sixteen  times,  and  the  revival  he  established  went  on 
growing  until  the  practice  was  carried  to  that  extreme  so  ably  ridiculed 
in  the  Dr.  Sangrado  of  Le  Sage.  Sebastian  Badus,  or  Baldus,  of  Genoa, 
who   has  the  merit  of   being  one  of-  the  earliest  advocates  of  the   use  of 

'  Peter  Brissot,  born  1478,  graduated  1514  at  Paris,  and  died  1522.  His  book  was 
only  printed  three  years  after  his  death  ;  it  was  reprinted  in  1623. 

^  De  curatione  per  sanguinis  missionem,  de  incidentse  venae,  cutis  scarifiandse,  et 
hirudinum  affingen  darum  modo  "  (8vo,  Antwerp,  1583). 


112  THERAPEUTICS    OF    THE    KESPIRATORY    PASSAGES. 

cinchona,  was  also  equally  in  favor  of  bleeding,  and  published  a  book  on 
the  necessity  of  bleeding  in  the  exanthemata,  in  1G63. 

But  time  would  fail  to  tell  of  the  many  worthies,  as  Fabricius,  Sil- 
vius,  Cfesalpinus,  and  the  illustrious  Harvey,  and  we  pass  on  to  Syden- 
ham, the  father  of  English  medicine,  who  required  all  his  perseverance 
and  genius  to  re-establish  the  example  of  Hippocrates.  He  bled  in  most 
acute  diseases — in  pleurisy,  bronchitis,  quinsy,  small-pox,  erysipelas, 
etc. — advising  a  full  bleeding  once  in  preference  to  repeated  small  ones. 
Pitcairn,  a  scholar  and  poet  as  well  as  a  physician,  continued  the  prac- 
tice. Rutherford  opposed  bleeding  in  bronchitis  and  some  other  dis- 
eases, but  he  bled  in  pleurisy  freely,  but  warns  against  excess. 

Hunter's  doctrines  seem  naturally  to  lead  to  free  bleeding,  and  ac- 
cordingly we  find  him  employing  it.  Cullen  succeeded  to  the  Chair  of 
Medicine  in  Edinburgh  in  1766,  published  his  "  First  Lines"  in  1784,  and 
from  that  time  to  his  death  held  the  very  highest  position  and  exercised 
the  greatest  influence.  He  employed  large  bleeding  as  a  portion  of  the 
antiphlogistic  system,  which  he  prescribed  in  almost  all  inflammations 
and  fevers,  with  a  view  to  take  off  the  "phlogistic  diathesis  "  and  to 
diminish  the  activity  of  the  "sanguiferous  system.''  He  bled  largely  in 
pleurisy,  as  much  as  the  patient  could  bear  ;  nor  did  he  hold  his  hand  in 
erysipelas.  Even  in  his  lifetime  some  opposition  was  raised,  for  Dr.  John 
Brown,  who  had  once  been  an  assistant  of  his,  set  up  a  directly  opposite 
system  of  stimulation,  especially  in  all  asthenic  diseases.  Unfortunately 
he  prescribed  stimulants  for  himself,  and  indulged  in  them  so  freely  that 
after  a  short  career  he  died  of  intemperance.  But  his  doctrine  of  stimu- 
lation obtained  no  little  repute,  expressing  perhaps  a  natural  reaction, 
and  affording  us  an  instance  of  history  repeating  itself  in  the  rise  and 
fall  of  doctrines. 

Pearson,  B,  Bell,  and  a  host  of  others  followed  Cullen.  Armstrong 
regrets  that  the  abstraction  of  160  ounces  of  blood  in  six  hours  did  not 
arrest  a  laryngitis,  and  he  was  in  favor  generally  of  bleeding  to  faintness. 
Cooper  and  Abernethy  were  imbued  with  similar  ideas — the  latter,  who 
professed  to  be  chary  of  taking  blood,  said,  "You  must  either  let  the  in- 
flammation kill,  or  run  the  risk  of  killing  the  patient  yourself."  His 
pupil  and  biographer,  George  Macilwain,  opposed  '  the  antiphlogistic  sys- 
tem. In  1836,  Robert  "Williams,  in  his  "  Elements  of  Medicine,"  rejected 
bleeding  in  erysipelas  and  gave  wine  freeh\  In  the  next  year  Majendie 
opposed  depletion  in  rheumatism;  still,  in  1843,  W.  P.  Alison  pronounced 
no  proposition  more  certain  "  than  that  Avhich  regards  the  power  of  large 
and  repeated  blood-letting  to  arrest  the  progress  of  inflammation  in  its 
early  stage."  Nevertheless  he  complains  that  some  teachers  seem  doubt- 
ful of  its  utility. 

'Medicine  and  Surgery  One  Inductive  Science.     London,  1838.    • 


DENUTRIENTS.  113 

Marshall  Hall,  who  had  long'  before  begun  to  write  upon  the  subject, 
attached  still  greater  importance  to  venesection,  advised  thirty  to  thirty - 
five  ounces  of  blood  to  be  taken  in  pleurisy  or  pneumonia,  and  fifteen 
ounces  in  bronchitis.  He  also  endeavored  to  set  up  bleeding  as  a  means 
of  diagnosis.  He  lived  to  see  his  views  on  this  subject  to  a  great  extent 
abandoned,  and  to  establish  his  fame  by  other  more  valuable  investiga- 
tions. Gooch,  Travers,  Kellie,  Abercrombie,  Copland,  and  even  Hall 
himself  pointed  out  conditions  in  which  loss  of  blood  was  injurious.  In 
1837  Skoda's  views  and  practice  were  brought  to  Edinburgh  by  G.  W. 
Balfour.  Pneumonia  he  considered  naturally  tended  to  recovery,  and 
therefore  did  not  require  the  customary  large  bleedings.  From  this  time 
the  practice  gradually  abated,  and  Todd,  who  in  1843  had  said  we  cannot 
cut  short  rheumatism  "as  we  can  arrest  an  attack  of  pneumonia  or  of 
pleurisy,"  eventually  laid  aside  the  lancet  and  became  the  exponent  of 
stimulating  treatment  in  London,  while  Hughes  Bennett  became  the 
leader  of  supporting  treatment  in  Edinburgh. 

We  have  now  arrived  at  the  period  when  the  practice  of  bleeding  last 
waned  ;  for  the  present  generation  has  not  revived  it,  and  venesection  is 
now  rarely  practised.  When  I  entered  the  profession  as  a  student,  about 
1852,  the  Brunonian  doctrine,  as  revived  by  Todd,  was  quite  in  the  as- 
cendant, and  in  London  I  saw  nothing  of  venesection;  but  it  survived  in 
the  provinces  and  I  often  saw  it  practised  there,  and  even  practised  it 
myself.  Having  been  taught  in  London  that  the  practice  was  in  abey- 
ance, it  was  surprising  to  see  how  some  practitioners  held  to  its  necessity 
in  the  country  ;  and  watching  the  cases  under  their  care  with  no  little 
scepticism,  I  had  to  confess  how  often  the  remedy  seemed  beneficial. 
They  mostly  admitted  that  in  cities  it  was  not  appropriate,  but  who  can 
forget  how  largely  it  had  been  practised  in  the  most  densely  populated 
districts  ?  Todd's  practice  continued  to  be  widely  followed  until  his  death, 
his  pupils  spreading  it  in  all  directions,  and  he  prescribed  alcohol  in  in- 
creasing quantities.  I  have  known  a  teaspoonful  of  brandy  given  to  a 
little  child,  by  his  advice,  every  five  or  ten  minutes  for  days  in  succession, 
and  the  considerable  quantity  prescribed  for  adults,  both  by  himself  and 
his  disciples,  is  matter  of  history.  Not  only  in  so-called  asthenic  diseases, 
but  in  fever  and  inflammation,  and  especially  in  pneumonia,  was  stimula- 
tion carried  to  as  great  an  excess  as  depletion  had  previously  been.  In 
erysipelas  and  serious  surgical  cases  I  have  seen  a  bottle  of  brandy,  be- 
sides twice  as  much  wine,  given  in  a  few  hours.  And  yet  this  was  not 
many  years  after  blood-letting  had  been  practised  with  as  great  excess. 
Marshall  Hall  was  then  living,  and  yet  a  man  who  had  broken  his  ribs 
had  been  almost  literally  bled  to  death  in  his  own  house,  and  he  himself 
mentions  a  case  in  St.  Bartholomew's  Hospital,  in  which  a  man  with 
broken  ribs  was  bled  twice  on  the  first  day,  eighteen  and  twenty,  ounces 
respectively;  on  the  second  day  he  was  twice  bled  to  eighteen  ounces;  on 


114  THERAPEUTICS    OF    THE    KESPIRATORY    PASSAGES. 

the  third  day,  as  the  pulse  was  jerky,  the  dresser  only  took  a  few 
ounces ;  by  direction  of  Lloyd  and  Lawrence  another  twenty  ounces 
was  taken,  after  which  "  the  pulse  became  a  mere  flutter  "  and  he  died. 
A  similar  instance  has  been  related  to  me  by  the  dresser  of  the  case  at 
the  London  Hospital  ;  this  also  was  a  fractured  rib.  On  admission  he  was 
bled  according  to  the  usual  practice  at  that  time  ;  the  next  day  he  was 
seen  by  the  surgeon.  Sir  William  Blizard,  who  ordered  him  to  be  bled 
again  ;  venesection  was  repeated  before  the  next  visit,  then  Blizard's 
attention  was  directed  to  his  failing  pulse,  upon  which  he  ordered  a 
further  bleeding  ;  this  was  carried  out,  and  shortly  after  the  patient  died, 
to  the  horror  of  the  young  dresser,  who  is  still  living. 

When  depletion  was  carried  to  such  an  extent  in  simple  accidents,  and 
in  all  cases  of  inflammation,  it  is  not  to  be  wondered  at  that  it  was  em- 
ployed as  a  preventive.  People  got  bled  as  thoughtlessly  as  they  now 
take  purgative  pills.  It  was  a  common  practice  to  be  bled  every  spring 
and  autumn.  Ladies  were  bled  to  improve  their  complexion,  and  the 
lancet  was  the  almost  universal  remedy  and  preventive.  A  vein  was 
opened  to  arrest  hemorrhage.  Women  were  bled  in  childbed.  Li  every 
country  surgery  young  apprentices  wielded  the  lancet  for  the  most 
trivial  ailments.  And  yet  of  the  thousands  who  for  a  long  series  of  years 
were  submitted  to  this  practice,  we  have  no  evidence  that  any  of  them 
suffered  from  the  customary  depletion — wnich  may  be  taken  to  show  that, 
in  health,  at  least,  a  moderate  loss  of  blood  is  easily  recovered  from  ;  and 
it  is  a  common  observation  also,  that  in  a  good  constitution  the  effects  of 
hemorrhage  from  an  accident  rapidly  pass  away. 

It  should  be  pointed  out  that  throughout  the  period  when  the  abuse 
of  bleeding  was  practised,  there  were  always  men,  though  in  a  minority, 
who  refused  to  follow  the  fashion.  At  the  London  Hospital,  one  of 
Blizard's  colleagues,  Mr.  T.  G.  Andrews,  though  he  often  bled  his  pa- 
tients, always  fed  them,  and  very  often  prescribed  stimulants  instead  of 
depletion,  so  that  it  became  a  proverb  among  the  pupils  that  Avhen  Bliz- 
ard said  "  bleed  him,"  Andrews  would  probably  say  "  feed  him  up,"  and 
so  many  severe  accidents  did  well  under  the  treatment  that  the  pupils 
came  to  consider  it  the  more  successful  method.  Another  curious  diver- 
gence of  practice  at  the  same  hospital,  and  at  the  same  period,  may  here 
be  mentioned  :  the  late  Dr.  Billing  bled  fever  patients  when  complicated 
with  pulmonary  congestion,  but  always  in  moderation  ;  the  elder  Davies 
salivated  them  ;  their  colleague,  Dr.  Frampton,  did  neither,  but  employed 
purgatives.  My  informant,  who  was  clerk  to  each  of  these  physicians  in 
turn,  tells  me  that  the  different  methods  were  watched  with  no  little  in- 
terest, and  that  the  mercurial  treatment  was  perhaps  the  most  popular 
of  all.  Dr.  Billing  told  me  that  as  the  pupil,  and  afterward  the  colleague 
of  Dr.  Frampton,  he  had  never  known  him  prescribe  venesection.  Dr. 
Billing  himself  would  bleed  patients  at  the  beginning  of  acute  inflamma- 


DENUTRIEISTTS.  115 

tory  diseases,  but  at  a  later  stage  he  employed  stimulants,  and  some- 
times he  would  use  them  from  the  beginning,  and  that  long  before  the 
Brunonian  revival  in  London — in  fact,  as  early  as  1831.  This  astute 
physician  lived  to  lay  aside  the  lancet  altogether,  and  though  he  never 
sanctioned  either  extreme,  was  by  no  means  averse  to  the  use  of  stimu- 
lants. Dr.  Little,  Billing's  pupil,  colleague,  and  successor,  followed  his 
practice,  feeding  some  of  his  patients  from  the  beginning,  but  he  often 
prescribed  depletion  in  the  early  part  of  his  career.  Before  he  resigned 
his  physiciancy  to  the  hospital  venesection  had  become  so  rare  an  opera- 
tion that,  more  than  once  when  he  prescribed  it,  neither  house-surgeons 
nor  dressers  had  seen  it  performed,  and  he  had  to  show  them  how  to  do 
it.     There  are  other  physicians  living  with  a  similar  experience. 

If  the  abuse  of  venesection  was  not  quite  universal,  the  change  in  prac- 
tice is  complete.  How  can  this  be  accounted  for  ?  Some  have  thought  that 
the  epidemics  of  influenza  in  1833  and  1837  are  to  be  credited  with  a  con- 
siderable share  in  bringing  about  the  change,  and  believe  that  from  about 
that  period  dates  a  change  of  type  in  disease  ;  but  perhaps  the  change  is 
quite  as  much  due  to  oscillation  in  medical  opinion,  for  practice  always 
follows  doctrine,  though  sometimes  longo  intervallo.  The  revival  of  hu- 
moral pathology  and  increased  interest  in  the  natural  history  of  disease 
greatly  tended  to  reverse  those  theories  which  led  to  depletion.  The 
change-of-type  hypothesis  looks  like  an  invention  to  account  for  the  re- 
versal of  practice  ;  but  Christison,  Stokes,  Watson,  and  other  great  clin- 
ical authorities  have  declared  that  they  observed  this  change  of  type. 
On  the  other  hand,  as  we  have  seen,  there  were  always  advocates  of  an 
opposite  treatment,  and  similar  reversals  of  practice  have  again  and  again 
marked  the  history  of  medicine. 

Bleeding  is  now  so  seldom  practised,  and  with  such  timidity,  that  it 
is  almost  outside  our  list  of  remedies  ;  and  yet  there  are  not  wanting 
physicians  among  us  who  now  and  then  resort  to  it,  and  who  believe 
that  it  is  too  much  neglected,  and  that  we  are  near  a  revival  of  the  prac- 
tice of  our  predecessors.  Assuredly  in  some  conditions  venesection  is 
able  to  give  speedy  relief,  and  the  experience  of  two  thousand  years 
shows  that  the  remedy  is  not  more  dangerous  than  some  others  we  con- 
tinue to  employ.  The  most  rational  indication  for  its  employment  is 
oppression  of  the  right  heart  with  distention  of  the  vascular  system. 
The  abstraction  of  a  few  ounces  of  blood  is  sufficient  to  relieve  this  con- 
dition. In  croup  and  larj-ngitis,  though  it  has  been  largely  used,  de- 
pletion has  always  proved  ineffectual.  The  organ  affected  is  small  and 
within  reach  of  other  remedies.  In  acute  pleurisy  the  severe  pain  and 
dyspnoea  is  certainly  relieved  by  bleeding.  In  pneumonia  coming  on 
suddenly  in  robust  patients,  with  hard  and  wiry  pulse  and  intense  op- 
pression of  breathing,  venesection  gives  great  relief,  the  pain  abates,  the 
fever  falls,   the  pulse    becomes    softer   and    fuller,   and    the    respiration 


116  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

comparatively  easy.  It  will  be  seen  tliat  it  is  the  embarrassment  of  the 
circulation  which  is  the  indication  relied  upon,  in  this  as  well  as  other 
cases.  Venesection  at  once  lowers  the  undue  blood-pressure,  and  so 
ought  to  cut  short  all  tlie  phenomena  depending  upon  that — and  it  is 
therefore  in  croupous  rather  than  catarrhal  pneumonia,  that  it  ought  to 
be  of  use.  In  complicated  cases  caution  has  always  been  enjoined.  In 
pleuro-pneumonia  the  more  moderate  of  our  predecessors  preferred 
leeches,  but  when  the  respiration  was  much  oppressed  they  would  open 
a  vein,  and,  as  we  have  said  before,  wherever  the  right  heart  is  suffer- 
ing from  the  vascular  tension  the  abstraction  of  a  few  ounces  of  blood 
will  relieve  it. 

Diseases  of  mucous  membranes  were  always  reputed  to  be  least 
amenable  to  antiphlogistics,  and  bronchitis  may  therefore  be  said  to  be 
little  influenced  by  depletion.  In  some  instances,  however,  when  the  pa- 
tient has  appeared  to  be  dying — his  face  blue  and  swollen,  with  purple 
lips,  suffused  eyes,  gasping  breath,  and  flickering  pulse — venesection  af- 
fords prompt  relief,  and  that  because  it  removes  the  distention  of  the 
right  heart,  and  thereby  enables  it  to  carry  on  its  work.  Such  a  condi- 
tion was  graphically  described  by  Dr.  Hare  last  year  in  his  presidential 
address,  since  published,  on  "  Good  Remedies  out  of  Fashion,"  in  which 
he  said  :  "  The  fact  is,  that  here  the  danger  lay  in  the  right  side  of  the 
heart  being  gorged  with  blood,  so  that  it  was  impossible  for  its  stretched 
and  distended  walls  to  contract  and  to  propel  forward  the  thick  and 
blackened  blood.  Oh,  as  you  value  your  j^tient's  life,  as  you  value  the 
blessed  consciousness  of  being  a  minister  who  has  done  everything  pos- 
sible for  his  welfare,  let  me  beg  of  you  not  to  be  contented  with  the  futile 
treatment  of  to-day  ;  relieve  that  poor,  oppressed,  distended  heart,  and 
all  may  be  well  !  " 

Lastly,  in  neuroses  our  predecessors  bled  cautiously  in  spasmodic  asth- 
ma when  the  oppression  was  excessive,  which  may  be  taken  to  mean  when 
the  engorgement  of  the  venous  system  oppressed  the  right  heart.  Thus 
all  through  the  diseases  of  the  respiratory  system  it  is  the  right  heart 
•which  is  relieved  by  bleeding.  It  is  true  that  agonizing  pain  and  dysp- 
noea are  also  relieved,  sometimes  as  if  by  magic,  especially  in  pleurisy 
and  pneumonia,  and  it  was  held  that  these  diseases  are  arrested,  or  at 
anv  rate  that  their  violence  is  abated  or  their  duration  shortened  by 
timely  venesection.  But  at  the  present  day  the  one  condition  which 
seems  likely  to  lead  to  the  operation  is  when  the  right  heart  appears 
overwhelmed.  The  instant  relief  to  this  state  is  most  grateful  to  the  pa- 
tient, often  leads  him  to  beg  for  a  repetition,  and  to  some  extent  ac- 
counts for  the  excesses  that  have  been  practised.  In  such  cases  even  so 
strenuous  an  advocate  of  feeding  as  Dr.  King  Chambers  would  not  hes- 
itate to  open  a  vein,  though  he  would  probably  prefer  a  number  of 
leeches,  at  the  same  time  ordering  support.     Such  practice,  though  some 


DENUTRIENTS.  117 

may  think  it  paradoxical,  is  in  reality  rational.  We  have  seen  it  followed 
by  Billing,  Little,  and  other  conscript  fathers  of  the  London  Hospital, 
and  may  now  and  then  find  it  resorted  to  even  to-day.  How,  then,  are 
we  to  account  for  the  prevailing  disuse  of  so  powerful  a  remedy  ?  It 
seems  to  me  that  this  is  to  a  considerable  extent  because  we  now  have 
other  remedies  by  which  we  can  often  attain  the  same  end  ;  but  few,  if 
any,  are  so  speedy. 

Local  blood-letting  by  leeches,  cupping-glasses,  or  scarification  is 
much  less  alarming,  but  the  reaction  against  depletion  has  well-nigh  ban- 
ished these  useful  methods.  Again,  dry  cupping  is  a  most  powerful 
remedy,  but  now  much  neglected.  Here  there  is  no  fear  of  loss  of  the 
vital  fluid,  but  it  is  only  rarely  resorted  to,  showing  how  much  our  ideas 
have  changed.  Again,  instead  of  removing  blood,  surgeons  sometimes 
endeavor  to  cut  off  its  supply  by  tying  an  artery  or  by  compression. 

COUNTER-IRRITATION. 

In  dry  cupping  blood  is  not  abstracted  from  the  body,  and  it  may 
therefore  be  classed  with  derivatives.  Here  we  attempt  to  draw  blood 
from  the  suffering  part  to  the  exterior,  or  wherever  it  may  be  less  inju- 
rious. The  foot-bath  is  a  simple  instance  of  a  mild  remedy  of  this  kind. 
Much  more  powerful  is  a  general  warm  bath  or  a  vapor  bath.  These 
last,  inasmuch  as  they  attract  blood  to  the  whole  surface  of  the  body, 
should  be  the  most  powerful  derivatives  ;  but  we  must  bear  in  mind 
that  this  only  represents  a  part  of  their  action,  and  therefore  their  other 
eft'ects  must  be  taken  into  consideration  before  employing  them,  effects 
whicli  extend  throughout  the  whole  system.  Often  we  prefer  to  apply 
our  derivatives,  revulsants,  or  counter-irritants  to  a  small  surface  ;  for 
this  purpose  we  may  employ  rubefacients  {rubere,  to  be  red,  facere,  to 
make),  or  those  which  cause  redness  of  the  part  with  heat  and  slight 
pain.  Sinapisms,  turpentine  stupes,  ammonia,  and  other  familiar  means 
may  be  employed  for  this  purpose,  but  hot  water  applied  by  either 
sponge  or  flannel  is  more  rapid  in  its  action,  much  less  irritating,  can  be 
renewed  at  intervals  extending  over  considerable  periods,  and  is  often 
most  effectual  ;  the  only  point  is  to  regulate  carefully  the  heat,  so  as 
only  to  produce  redness  and  not  to  scald  or  blister.  Dr.  Graves  treated 
croup  in  this  way,  and  was  convinced  of  the  great  value  of  the  remedy. 
A  little  less  degree  of  heat  is  more  frequently  applied  in  poultices  and 
fomentations  ;  these  undoubtedly  relieve  pain,  even  when  deep-seated, 
and  are  at  the  same  time  soothing,  probably  through  the  nervous  system. 
These  milder  applications  should  be  applied  over  a  larger  area  than  the 
disease  is  supposed  to  occupy,  and  their  influence  is  certainly  not  merely 
derivative  or  rubefacient.  The  chest  may  be  enclosed  in  a  linseed-meal 
jacket  in  pneumonia  and  other  respiratory  diseases  ;  the  effect  of  such  a 


118  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

jacket  is  certainly  soothing,  and  it  deserves,  therefore,  to  be  regarded 
rather  as  a  sedative  than  an  irritant  ;  just  as  fomentations  are  assuredly 
anodyne,  though  so  far  as  the  vascular  system  is  concerned,  both  draw 
blood  to  the  surface. 

When  more  active  counter-irritation  is  required,  epispastics  (cTrt,  upon, 
and  o-Trddi,  I  draw),  or  vesicants  (vesica,  a  blister)  may  be  resorted  to. 
These  produce  so  much  irritation  that  the  part  becomes  inflamed,  and  the 
epidermis  is  raised  so  as  to  form  a  blister  by  the  serum  which  escapes 
from  the  vessels.  More  pain  is  caused  by  these  applications,  and  instead 
of  the  slight  excitement  produced  by  the  rubefacients,  there  is  depression, 
and  if  the  area  operated  on  be  large,  this  is  evinced  by  slower  circula- 
tion and  respiration,  with  a  fall  of  temperature.  A  still  greater  degree 
of  counter-irritation  may  be  obtained  from  pustulants,  issues,  and  the 
moxa.  Here  suppuration  is  set  up,  and  the  old  humoralists  taught  that 
noxious  materials  were  thus  removed  from  the  blood.  In  these  last  cases 
the  effect  is  usually  prolonged  ;  thus  it  was  once  a  common  practice  to 
keep  an  issue  open  for  many  vpeeks  in  certain  intractable  chronic  dis- 
eases. For  a  more  rapid  and  extensive  effect  in  acute  cases  a  blister 
■was  frequently  dressed  with  an  irritant  ointment,  so  as  to  bring  about 
free  suppuration.  The  tendency  now  is  to  restrict  counter-irritation  to 
the  milder  methods. 

The  effects  of  counter-irritation  have  been  referred,  perhaps  too  ex- 
clusively, to  the  circulation.  The  more  active  a  part  the  more  blood  Hows 
to  it — ubi  stimulus  illuc  affluxus — and  so  the  effort  has  been  made  to  de- 
rive the  blood  to  a  less  vital  part.  But  more  than  this  must  be  involved, 
the  inter-arterial  sympathies  must  be  under  the  control  of  the  vaso-motor 
system,  through  which,  no  doubt,  various  vascular  areas  related  to  each 
other  may  be  affected  one  by  another,  and  the  vascular  connection  be- 
tween these  may  be  direct  or  indirect.  Then,  again,  areas  may  be  con- 
nected with  each  other  through  the  nervous  system,  and  such  connection 
also  may  be  direct  or  indirect.  How  very  indirect  it  may  sometimes  be 
we  may  perhaps  understand  if  we  suppose  the  local  irritation  to  pass  to 
the  nervous  centres  controlling  the  irritated  skin,  with  so  much  intensity 
as  to  overflow,  so  to  say,  to  adjoining  or  neighboring  centres  ;  these  dis- 
charging laterally  would  then  influence  the  periphery  of  other  vaso-motor 
or  trophic  centres.  Be  that  as  it  may,  the  practice  is  ancient,  and  if  at 
times  carried  to  extremes,  no  one  can  doubt  that  the  less  severe  methods 
are  of  great  utility. 

The  more  severe  the  local  irritation,  and  the  greater  the  pain  pro- 
duced, the  more  cautious  should  we  be  in  instituting  the  treatment. 
Even  blisters,  which  unless  too  large  may  be  considered  of  medium 
severity  are  sometimes  injurious.  In  thoracic  diseases  they  have  been 
almost  universally  employed,  and  yet  so  able  an  observer  as  Skoda  de- 
clared he  had  never  seen   them   do  any  good,  though    they  often  did 


DENUTRIENTS.  119 

harm.  Many  will  be  ready  to  think  that  this  must  have  been  because  in 
Germany  they  were  applied  to  large  surfaces  and  dressed  with  irritants  ; 
for  moderate-sized  blisters  allowed  to  heal  at  once  seldom  do  mischief, 
but  large  ones  made  to  suppurate  and  other  severer  methods  will  in- 
crease fever  and  cause  much  nervous  depression.  Moreover,  may  not 
too  severe  counter-irritation  aggravate  the  condition  it  is  intended  to  re- 
lieve ?  for  if  a  mild  counter-irritant  can  affect  a  part  in  the  manner  we 
have  indicated,  it  would  seem  possible  that  a  violent  remedy  of  the  same 
kind  might  influence  the  organ  so  much  as  to  exaggerate  the  inflamma- 
tion. In  support  of  this  view  it  may  be  stated  that  blisters  are  not 
always  intended  to  act  as  derivatives  ;  e.g.,  chronic  synovitis  of  the  knee- 
joint  is  sometimes  treated  by  blistering,  under  which  it  is  not  uncommon 
to  observe  an  increase  of  the  effusion,  evidently  caused  by  the  stimulus 
propagated  from  the  surface,  and  it  is  only  after  the  subsidence  of  the 
fresh  inflammation  that  the  swelling  begins  to  diminish.  At  the  same 
time,  Dr.  Herbert  Davies'  method  of  treating  acute  rheumatism  is  to 
freely  blister  round  and  near,  but  not  immediately  over  the  affected 
joints,  so  that  this  treatment  may  be  really  derivant,  and  certainly  it  does 
not  produce  any  preliminary  increase  of  the  effusion. 

Rapid  rubefacients  and  vesicants  are  of  course  the  more  appropriate 
in  acute  diseases  ;  more  slowly  acting  counter-irritants  are  naturally  pre- 
ferred in  chronic  cases.  The  time  required  for  the  production  of  the  ef- 
fect thus  becomes  the  chief  indication  in  the  selection  of  the  application, 
excepting  always  its  severity,  in  regard  to  which  it  is  perhaps  a  good 
rule  to  employ  the  mildest  which  seems  likely  to  achieve  the  desired  re- 
sult. 

EVACUANTS. 

Evacuants  afford  another  mode  of  depleting,  by  hastening  the  removal 
from  the  system  of  some  constituents  no  longer  required,  or  even  of  others 
for  w^iich  uses  might  yet  be  found.  The  most  common  and  perhaps  the 
most  direct  and  powerful  group  of  evacuants  is 

Purgatives. — Hippocrates  had  a  very  high  opinion  of  purging,  be- 
lieving that  it  attracted  "  peccant  "  humors  and  discharged  them  from 
the  system.  He  used  drastics  of  the  harshest  kind,  which  also  acted  as 
emetics.  Purgation  has  maintained  its  place  until  our  own  time,  not  with- 
out its  ups  and  downs,  it  is  true,  but  these  have  been  less  marked  than 
those  of  phlebotomy.  No  doubt  the  use  of  milder  aperients  has  helped  to 
maintain  the  favor  in  which  these  evacuants  are  held.  It  may  be  said  that 
slight  cordial  aperients  are  scarcely  to  be  regarded  as  depletive,  but  even 
moderate  increase  of  intestinal  action  is  to  some  extent  denutrient,  since 
the  removal  of  water  even,  or  the  mere  hastening  of  the  transit  of  the  con- 
tents of  the  alimentary  canal  may  suflBce  to  prevent  the  absorption  of  some 
of  the  nutriment,  and  so  deprive  the  blood  of  that  amount.     So  much 


120  THERAPEUTICS    OF   THE    EESPIRATORY    PASSAGES. 

quickening,  however,  might  only  act  as  a  stimulus,  and  fresh  supplies 
coming  in  might  therefore  be  taken  up  more  readily;  thus  indirectly  nutri- 
tion would  be  improved.  This  would  be  more  marked  should  any  undue 
accumulation  be  thereby  unloaded.  In  the  same  way  the  bile  is  swept 
along,  and  its  production  may  thereby  be  stimulated,  while  other  excre- 
mentitious  substances  are  got  rid  of.  No  doubt  the  portal  system  is  at 
the  same  time  relieved,  its  volume  of  blood  being  temporarily  reduced,  and 
later  still  the  heart  and  general  vascular  system  are  similarly  affected  by 
the  increased  amount  of  fluids  removed.  We  notice,  therefore,  that  the 
blood-pressure  falls,  the  respiration  is  easier,  and  the  cerebral  circulation  is 
no  doubt  depressed,  so  that  while  the  head  may  feel  relieved  by  moderate 
purgation  and  the  person  enjoy  a  feeling  of  lig-htness,  faintness  may 
ensue  in  case  of  excessive  action,  and,  of  course,  this  is  more  likely  to 
occur  in  the  aged  or  feeble. 

Quite  mild  cordial  aperients  (aperio,  I  open)  may  bring  about  most  of 
the  results  we  have  mentioned,  and  even  the  regulation  of  the  diet  may 
be  made  to  accomplish  much,  but  for  more  decided  antiphlogistic  effects 
stronger  cathartics  {KaOatpw,  I  cleanse)  are  required  ;  Abernethy's  favorite 
blue  pill  and  black  draught  is  one  of  the  most  effectual.  The  saline  laxa- 
tives (laxo,  I  loosen)  especially  promote  osmosis  into  the  intestines,  while 
others,  such  as  senna,  act  chiefly  by  increasing  peristalsis,  hence  the  value 
of  a  combination  of  these  two  groups,  such  as  is  well  represented  in  black 
draught.  "When  more  sudden  and  violent  action  is  required,  drastics 
(Spdo),  I  act)  are  resorted  to,  such  as  colocynth,  gamboge,  elaterium,  or  cro- 
ton  oil  ;  these  set  up  catarrh  of  the  mucous  membrane,  more  or  less  in- 
tense according  to  the  dose  and  other  circumstances.  They  thus  remove  a 
good  deal  of  solid  constituents  of  the  blood  as  well  as  water,  and  are  so 
irritant  as  to  demand  much  more  circumspection  in  their  use.  Those 
which  cause  profuse  evacuation  of  water  are  distinguished  as  hydra- 
gogues  (uSw/3,  water,  ayw,  to  drive),  but  some  of  these  are  quite  mild,  and 
apparently  only  increase  the  secretion  of  -^ater  into  the  canal,  whence  it  is 
likely  to  be  reabsorbed,  unless  combined  with  another  purgative  which 
acts  by  stimulating  the  peristaltic  movements.  These  movements  may 
indeed  be  increased  by  medicines  which  cannot  be  called  aperient,  but 
which  on  account  of  this  property  are  valuable  adjuvants  to  such  reme- 
dies. Nux  vomica  is  an  example.  We  have  seen  that  liquid  poured  into 
the  bowel  may  be  rapidly  reabsorbed,  and  it  is  probable  that  some  of  our 
purgatives  really  stimulate  the  intestinal  glands  ;  this  seems  to  be  the  case 
■with  mercury,  and  perhaps  also  with  the  salines.  It  is  not  improbable, 
that  the  drastics  do  so,  but  their  other  action  overpowers  this.  Jalap 
and  scammony  seem  to  require  the  presence  of  bile  to  dissolve  them. 

It  will  be  observed  that  the  antiphlogistic  action  of  purgatives  is  a 
complex  one.  They  reduce  vascular  tension  by  withdrawing  fluid  from 
the  circulation,  and  that  in   proportion  to   the  amount  removed.     Then 


DENUTRIENTS.  121 

they  not  only  take  away  water,  but  albuminous  matter,  and  in  this  way 
impoverish  the  blood,  thus  they  really  deplete  ;  further,  they  eliminate 
various  effete  matters  and  quicken  tissue  metamorphosis  ;  moreover, 
they  counter-irritate.  It  is  not  always  easy  to  assign  to  these  modes  of 
action  their  relative  share  in  the  result,  but  the  use  of  purgatives  is,  as 
we  have  seen,  very  ancient  and  almost  universal.  It  is  usual  to  com- 
mence the  treatment  of  inflammatory  diseases,  even  those  affecting  the 
respiratory  organs,  by  this  form  of  depletion,  selecting  the  dose  accord- 
ing to  the  strength  of  the  patient  and  the  severity  of  the  case.  Even  in 
weakly  persons  it  is  well  to  unload  the  bowels,  and  this  generally  pro- 
duces a  good  effect,  the  diminution  of  vascular  tension  tending  to  relieve 
the  oppressed  breathing  and  acting  favorably  on  the  liver  and  the  heart. 

Mercury. 

Mercury  has  been  named  among  the  purgatives,  and  is  still  believed 
by  many  to  be  cholagogue  [ypkr],  bile,  ayw,  to  drive),  if  only  indirectly; 
it  is  also  regarded  as  antiphlogistic,  and  perhaps  its  sialagogue  (crtaA.ov, 
saliva,  ayw,  to  lead)  properties  further  entitle  it  to  a  place  among  evacu- 
ants — it  is  therefore  conveniently  considered  here. 

Mercury  has  been  used  for  a  long  period  in  many  diseases.  It  was 
employed  externally  by  Rhazes  and  Avicenna.  Paracelsus  is  usually 
credited  with  being  the  first  to  give  it  internally,  but  probably  he  was 
not,  for  although  he  would  have  been  reckless  enough  to  employ  any- 
thing which  suggested  itself  to  his  mind,  he  was  much  more  likely  to 
appropriate  what  he  found  in  use  than  to  originate  anything  new.  He 
would,  however,  be  likely  enough  to  use  powerful  medicines  in  full  doses, 
and  very  frequently.  Before  his  time  mercury  was  employed  by  inunction 
in  order  to  produce  salivation,  as  we  may  learn  from  the  writings  of  Al- 
menar,'  John  de  Vigo,"  physician  to  Pope  Julius  II.,  Berengarius  Carpen- 
sis,  and  iVloysius  Lobera  ; '  also  from  his  contemporary,  Fracastorius,  the 
poet-physician,  who  in  his  remarkable  poem,  published  in  1530,  lauded 
fumigations  with  cinnabar  ;  a  little  later,  Rondelatius,  1583,  gives  di- 
rections and  formulae  for  such  fumigations — these  writers,  apparently 
long  anticipating  the  modern  use  of  calomel  vapor-baths.  Almenar,  like 
the  Arabians,  did  not  approve  of  salivating  his  patients,  and  tried  to  re- 
strain this  effect  by  means  of  purgatives  and  other  treatment.  Here 
again  we  observe  an  anticipation  of  the  modern  conclusion  that  saliva- 
tion is  to  be  avoided  ;  he,  however,  recommended  fumigations  as  most 
admirable  in  inveterate  disease.  We  find  Fallopius,  in  1565,  using  mer- 
cury internally,  in  the  form  of  his pilula  ex prcecipitato,  and  before  then, 

'  Libellus  de  morbo  gallico.     1512.  '  Liiisinus  a  aphrodisiacus,  etc.     1566. 

^  Vide  Luisinus  ;  also  Turner's  Summary  of  the  same. 


122  THERAPEUTICS    OF   THE    EESPIKATOEY   PASSAGES. 

15G3,  Bayrus  tells  us  of  a  pill  called  2nlida  contra  morhum  gallicum, 
which  was  in  great  repute  in  his  time,  and  of  which  the  principal  ingre- 
dient was  a  mercurial. 

Passing  over  more  than  a  century,  we  find  the  use  of  mercury  gradu- 
ally extending  itself,  until  in  1700,  Camerarius  '  and  Caspar  ^  are  writing 
of  it  as  a  panacea,  and  Hoffmann  ^  is  recommending  it  in  many  obstinate 
diseases.  Forty  years  afterward,  Stenzel  ^  and  Havighorst  ^  directed  atten- 
tion to  the  value  of  calomel  as  a  resolvent.  In  1769,  Cavallieri "  was  ad- 
vocating its  use  in  rheumatic  paralysis.  By  this  time,  and  indeed  earlier, 
the  administration  of  mercury  seems  to  have  been  common  in  various 
fevers,  and  soon  after  Lysons  '  published  an  essay  on  the  use  of  calomel 
and  camplior  in  continued  fevers,  which  he  followed  up  with  further  ob- 
servations six  years  after  his  first  publication. 

This  use  in  fever  continued  to  grow,  and  we  find  Dr.  Davis*  chiefly 
relied  on  mercury  and  purgatives  in  the  terrible  Walcheren  fever,  and 
the  value  of  mercury  continued  to  be  accepted  until  quite  our  own  times. 
Thus  we  find  Dr.  Copland  '■"  remarking  that  death  after  salivation  has 
been  established  is  very  rare  ;  and  Pereira  "  tells  us  his  experience  was 
the  same,  but  Graves"  pronounced  the  use  of  mercury  to  be  injudicious 
in  fever  unless  inflammation  of  some  organ  were  set  up.  In  1778  Fow- 
ler'^  recommended  mercury  in  small-pox,  and  two  years  later  Langguth  '' 
in  dropsy.  In  1784  Dr.  Houlston  '*  urged  the  value  of  inunctions  in  dys- 
entery, and  Nevison  '^  about  this  time  in  intestinal  obstructions. 

During    this   time  many   extravagances  were  committed    in  the  em- 

'  CamerariiTS,  R.  J. :  De  panacea  mercuriali.     1700. 
-  Caspar,  J.  :   Dissertatio  de  panacea  mercuriali.     1700. 

*  Hoffmann,  F.  :  De  mercurio  et  medicamentis  mercurialibus  solutis  ad  expugnan- 
dos  sine  salivatione  morbos  corporis  humani  rebelles.     1700. 

*  Stenzel,  C.  G.  :  De  mercurio  dulci  praestantissimo  pituitae  resolvendae  et  evacuan- 
dse  remedio.     1743. 

'  Havighorst,  J.  :  De  singulari  mercurii  dulcis  usu  in  desperatis  quibusdam  morbis. 
1745. 

*  Cavallieri,  G.  :  Storia  d'una  rlieumatica  paralisia  curata  con  uuzione  mercuriale. 
1769. 

"  Lysons,  D.  :  Essay  on  the  Effects  of  Campliire  and  Calomel  in  Continued  Fevers. 
1771.     Further  Observations,  etc.     1777. 

*  Davis,  J.  B.  :  Account  of  the  Fever  of  Walcheren.     1810. 
^  Copland,  J.  :  Dictionary  of  Practical  Medicine.     1858. 

'"  Pereira,  J.  :  Materia  Medica,  vol.  i.     1849. 

"  Graves,  R.  J.  :  Clinical  Lectures  on  the  Practice  of  Medicine.     1848. 

'*'  Fowler,  T.  ;  De  methodo  medendi  Variolam  prsecipue  auxilio  mercurii.     1778. 

"  Langguth  :  De  mercurio  dulci  potentissimo  Hydropis  domitore.     1780. 

"  Houlston,  T.  :  Observations  on  Poisons  and  on  the  Use  of  Mercury  in  the  Cure  of 
Obstinate  Dysenteries.     1784. 

'^  Nevison,  A.  S.  :  On  the  Use  of  Crude  Mercury  in  Obstructions  of  the  Bowels. 
1786. 


DENUTRIENTS.  123 

ployment  of  mercury,  but  many  protests  were  also  entered  against  its 
abuse,  which,  however,  was  destined  to  reach  larger  dimensions.  The 
train  had  now  been  duly  laid,  and  a  small  but  very  important  contribu- 
tion appeared  in  1785,  by  Dr.  Robert  Hamilton,'  which  was  destined 
to  exercise  very  wide  influence.  He  introduced  the  use  of  calomel  and 
opium,  which  continued  to  be  a  favorite  combination  for  nearly  three 
quarters  of  a  century  ;  and,  indeed,  I  have  seen  it  emploved  by  many 
practitioners  even  later  than  that.  It  is  true  that  calomel  had  been  em- 
ployed in  inflammations  much  earlier  than  this,  and  was  in  use  even  in 
America  prior  to  that  date,  as  shown  by  Dr.  Beck  ;  ^  but  the  combination 
with  opium  was  certainly  an  important  advance,  and  this  is  generally 
credited  to  Dr.  Hamilton,  who  certainly  succeeded  in  impressing  its  value 
on  British  physicians  to  such  an  extent  that  it  became  quite  routine 
practice  to  give  it  in  every  inflammatory  condition,  and  mercury  was  per- 
haps as  much  abused  as  blood-letting.  Not  that  Dr.  Hamilton  alone  is 
to  be  held  responsible  for  this,  for  he  was  soon  afterward  supported  by 
numerous  writers,  among  whom  we  may  mention  Goy,'  Rambacli,* 
Maclean  and  Yates,^  and,  at  the  close  of  the  century,  Abernethy,"  whose 
influence  it  would  be  difficult  to  exaggerate.  It  is  not  necessary  to  con- 
tinue the  history  through  the  first  half  of  the  present  century,  as  that  will 
be  more  familiar  to  our  readers  ;  nor  need  we  say  that  from  time  to  time 
most  powerful  opposition  to  mercurials  was  offered  ;  indeed,  that  much 
may  be  said  respecting  the  whole  history,  for  in  1562  it  was  denounced 
by  D.  Leoni  (Luisinus)  as  a  poison  which  produced  tremors,  convulsions, 
paralysis,  and  a  host  of  other  nervous  symptoms  ;  and  his  denunciations 
were  reiterated  in  various  forms  and  with  many  additions  by  a  number 
of  writers  down  to  our  own  times,  when  the  anti-mercurial  crusade  has 
been  led  by  Dr.  Hughes  Bennett  and  his  followers. 

Mercury  is  speedily  absorbed,  produces  important  effects  on  the 
blood,  and  passes  rapidly  into  the  tissues,  in  which  it  lingers.  It  must 
exercise,  therefore,  a  most  important  effect  on  nutrition.  In  the  blood 
it  destroys  the  red  corpuscles,  but  in  small  doses  this  effect  is  not  neces- 
sarily produced.  Syphilitic  patients  improve  under  its  influence,  and  if 
anaemic,  the  red  globules  increase  instead  of  diminishing-  in  number  ; 
but  if  the  remedy  should  be  continued,  its  usual  effect  will  be  manifest. 
We  infer  from  this  that  the  benefit  must  arise  from  the  antagonistic 
influence  upon  the  disease.     It  is  only  when   given  in  quite   small  quan- 

'  Hamilton,    Robert :    Letter  to  Dr.   Duncan,  giving  an  Account  of   a  Successful 
Method  of  Treating  Inflammatory  Diseases  bj  Mercury  and  Opium.     1785. 
^  Beck,  J.  B.  :  Essays  on  Infant  Therapeutics.     1849. 
^  Goy,  J.  ;  De  virtute  mercurii  inflammationes  resolvente.     1794. 
*  Rambach,  J.  J.  :  Usus  mercurii  in  morbis  inflammatoriis.     1794. 
^  Maclean,  C,  and  Yates,  W.  :    The  Science  of  Life,  etc.     1797.  '  - 

'  Abernethy,  John  :  Surgical  and  Physiological  Essays.     1797. 


124  THERAPEUTICS    OF    THE    EESPIRATOEY    PASSAGES. 

titles  tliat  the  blood  is  improved,  wliile  larger  doses  impoverish  it.  This 
has  been  shown  not  only  by  analysis,  but  by  the  investigations  of  Wil- 
bouchewitz  (Archives  de  Physiologie,  1874),  following  the  method  of 
Malassez  for  counting  the  corpuscles.  Dr.  Keyes,  however,  has  stated 
that  in  all  persons,  whether  syphilitic  or  not,  minute  doses  will  temporarily 
increase  the  red  globules  [Amer.  Journal  of  the  Med.  Sciences,  187G). 
But  before  then  the  impoverishing  influence  on  the  blood  had  been  con- 
stantly noticed.  Thus,  as  early  as  1757  Huxham  '  had  said  that  "  a 
lono-  and  large  use  of  mercury  will  turn  the  whole  mass  of  blood  into  a 
mere  watery  colluvies."  And  modern  writers  have  employed  similar 
expressions  :  e.g.,  Dr.  Farre  ^  speaks  of  mercury  as  "  positively  anti- 
phlegmonous,"  and  he  also  relates  the  following  incident  :  "  A  full,  ple- 
thoric woman,  of  a  purple-red  complexion,  consulted  me  for  hemorrhage 
from  the  stomach,  depending  on  engorgement,  without  organic  disease. 
I  gave  her  mercury,  and  in  six  weeks  blanched  her  as  white  as  a  lily." 
Pereira  ^  classed  mercury  among  his  spanoimics  as  a  resolvent  or  lique- 
facient.'  Headland,  Gubler,  Trousseau,  and  many  others  confirm  the 
disintegrating  and  destructive  effect  of  mercury  on  the  corpuscles.  On 
the  general  nutrition,  although  many  observations  show  that  it  seems 
to  exercise  in  minute  quantities  a  favorable  influence,  it  is  only  so  in  a 
state  of  disease,  and  may  therefore  be  well  called  an  alterative,  while 
even  in  syphilis  large  doses  not  only  impoverish  the  blood  but  impair 
nutrition,  increase  tissue  waste,  and  bring  about  emaciation. 

Mercurials  certainly  promote  secretion  and  excretion,  as  they  stim- 
ulate the  glandular  system  and  quicken  absorption.  They  are  generally 
held  to  affect,  first  of  all,  newly  formed  or  ill-organized  tissues.  The  pre- 
cise modus  operandi  is  not  known,  but  we  may,  perhaps,  conjecture  that 
in  some  way  they  check  the  growth  of  young  cells.  On  the  whole  they 
are  certainly  denutrients,  though  when  they  become  curative  of  course 
their  indirect  influence  is  to  restore  nutrition. 

Mercury  is  eliminated  to  some  extent  by  all  the  excretions,  but 
chiefly  by  the  kidneys  ;  the  rate  at  which  it  is  excreted  has  been  care- 
fully studied  by  Mayenyon  and  Bergeret  (Robin's  Journal  de  V Anat- 
omie,  1873,  and  subsequently  Lyon  Medical),  who  found  that  after  one 
centigramme  of  perchloride  given  to  a  dog  subcutaneously,  the  urine 
contained  mercury  for  twenty-four  hours.  When  the  dose  was  given 
daily  for  ten  or  twelve  days,  the  metal  was  detected  for  four  or  five  days 
after  the  dose  was  discontinued.  In  another  series  of  experiments  on 
rabbits,  which  were  killed  at  different  periods,  they  found  the  metal  in 
half  an   hour  after  the  dose  in  all  the  tissues,  but  most  in  the  liver  and 


'  Huxham  :  Essay  on  Fevers. 

2  Farre  :  Ferguson's  Essays  on  the  Most  Important  Diseases  of  Women.     1839. 

3  Pereira,  J.  :  Materia  Medica,  vol.  i.,  p.  175.     1849. 


DENUTRIENTS.  125 

kidneys.  After  four  days,  sometimes  less,  a  single  dose  could  not  be 
detected.  Thus  it  would  appear  that  a  siiig'le  dose  may  not  remain  in 
the  system,  but  the  same  observers  have  proved  that  when  repeated 
doses  are  given  elimination  will  cease  before  it  is  all  excreted.  On  one 
occasion  forty-eight  hours  after  a  course  of  mercury  had  been  discon- 
tinued it  could  no  longer  be  detected  in  the  urine  ;  iodide  of  potassium 
was  then  given,  upon  which  a  large  quantity  of  mercury  was  excreted, 
and  the  elimination  continued  for  seventy-two  hours,  diminishing  grad- 
ually. 

As  an  antiphlogistic  the  use  of  mercury  was  for  more  than  half  a 
century  almost  universal.  It  is  now  only  seldom  used  for  that  purpose, 
and  when  it  is  employed,  with  a  view  of  counteracting  the  effect  of  the 
syphilitic  poison,  its  impoverishing  effect  on  the  blood  is  so  fully  recog- 
nized that  in  these  days  nutritious  diet  is  generally  insisted  on  as  at  the 
same  time  necessary.  The  evidence  of  its  antiphlogistic  value  is  almost 
necessarily  only  clinical,  and  naturally  it  is  open  to  serious  doubt. 
Nevertheless,  this  evidence  is  so  extensive  that  it  is  difficult  to  deny 
that  the  conclusion  so  long  universally  accepted  and  in  accordance  with 
so  many  daily  recurring  observations  has  some  foundation  in  facts.  It 
was  long  held  that  mercurials  were  most  serviceable  in  inflammations  of 
serous  membranes  ;  it  was  believed  to  check  the  tendency  of  fibrous 
exudations,  and  even  to  promote  their  reabsorption.  Hence  it  was  but 
natural  to  rely  upon  it  in  pleurisy  and  other  allied  inflammations,  and 
yet  this  method  of  treatment  has  now  become  almost  obsolete.  Iritis  is 
somewhat  analogous  to  serous  inflammations. 

Pneumonia  is  a  good  example  of  the  parenchymatous  inflammations 
in  which  mercury  was  long  held  to  be  absolutely  necessary,  and  this  dis- 
ease was  for  some  time  made  the  battle-ground  between  those  who  ad- 
vocated and  those  who  condemned  this  treatment,  just  as  we  have  seen 
it  was  in  reference  to  blood-letting,  and,  we  may  add,  the  antiphlogistic 
system  altogether.  In  inflammation  of  mucous  membranes  mercury  was 
held  to  be  less  desirable,  and  perhaps  in  the  respiratory  tract  it  never 
obtained  the  same  credit  as  elsewhere  ;  at  any  rate,  in  this  locality  it 
went  out  of  f asliion  earlier,  though  in  acute  cases  it  was  often  resorted  to. 
As  efficient  purgatives  some  of  the  preparations,  especially  in  combina- 
tion with  other  cathartics,  are,  as  we  have  seen,  frequently  most  useful. 

With  regard  to  special  respiratory  diseases,  some  physicians  continue 
to  employ  mercurial  preparations  to  some  extent,  e.g.^  Dr.  Phillips  says 
he  has  found  small  doses  of  gray  powder  cure  coryza  more  quickly  than 
any  other  remedy,  "especially  when  there  is  much  sneezing,"  and  he  says 
that  *'  catarrh  affecting  the  Eustachian  tube  is  also  well  treated  in  the 
same  manner  "  ("  Materia  Medica,"  *'  Inorganic,"  p.  662).  It  appears 
to  me  that  in  the  latter  case  there  is  nowadays  no  necessity  to  resort  to 
such  treatment,  and  in  the  former  few  people  will  be  inclined  to  adopt  it. 


126  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

In  tonsillitis  and  in  pai'Otitis  mild  mercurials  are  still  sometimes  re- 
commended ;  but  by  no  means  inconsiderable  experience  in  these  aifec- 
tions  leads  me  to  reject  them  as  unnecessar\',  and  the  same  observation 
may  be  ventured  respecting  various  other  diseases  of  the  throat.  Many 
practitioners  still  regard  rapid  mercurialization  as  highly  desirable  in 
acute  laryngitis — they  are  under  the  impression  that  it  will  prevent  the 
development  of  oedema  of  the  glottis  ;  but  considering  the  great  ad- 
vances that  have  been  made  in  our  ability  to  control  laryngeal  diseases 
and  to  cope  with  their  dangers,  it  is  but  natural  to  discard  a  remedy  the 
value  of  which  is  at  the  best  doubtful,  and  confidence  in  which  is  too 
likely  to  lead  to  the  omission  of  more  reliable  measures. 

Jn  acute  bronchitis  where  there  is  much  congestion  and  but  little 
expectoration,  with  severe  cough  at  night,  pyrexia,  and  dvspnoea,  many 
authorities  still  give  mild  mercurials  ;  but  such  treatment  should  certainly 
be  reserved  for  robust  patients  in  the  prime  of  life,  and  even  then  should 
occupy  only  a  subordinate  position.  Dr.  Thorowgood  has  used  blue  pill 
with  squill  in  such  cases  {Practitioner,  1878).  Minute  doses  of  antimony 
would  seem  more  appropriate  to  such  a  condition,  and  if  supplemented  by 
warm,  soothing  inhalations  are  generally  successful  ;  the  squill  is  better 
reserved  for  a  later  period,  and  then  possibly  mercury  will  be  considered 
unnecessary. 

In  broncho-pneumonia  ointment  or  the  oleate  is  sometimes  applied 
to  the  chest,  or  when  a  blister  has  been  considered  necessary  it  may  be 
dressed  with  mercurial  ointment. 

In  diiyhtheria  there  are  not  wanting  able  observers  who  still  resort 
to  mercury.  Bretonneau  used  it  freely,  but  with  very  little  success, 
Trousseau  employed  calomel  locally  by  insufflation,  West  believed  it 
counteracted  tlie  tendency  to  form  false  membrane,  and  Stille  considers  it 
urgent  to  bring  the  system  under  its  influence  as  quickly  as  possible. 
On  the  other  hand,  so  little  benefit  has  followed  the  use  of  mercury  that 
the  majority  seem  for  some  years  to  have  rejected  it.  With  other 
methods  of  more  decidedly  and  even  more  rapidly  influencing  the  mu- 
cous membrane,  and  with  the  doubt  that  hangs  about  the  power  of  mer- 
cury to  do  this,  together  with  the  probability  that  any  excess  would 
rather  encourage  than  restrain  the  spread  of  the  exudation,  I  have  gen- 
erally discountenanced  its  use  and  relied  upon  measures  which  seem  to 
me  more  direct,  and  therefore  more  likely  to  be  of  service.  Still  there 
is  such  a  mass  of  experience  recorded  in  favor  of  mercury  by  English, 
American,  French,  and  German  authors  that  many  may  hesitate  to  omit 
its  use.  In  such  case  let  them  be  careful  to  proceed  cautiously  and  to 
watch  the  effect,  and  to  employ  it  rather  with  a  view  to  its  action  upon 
the  mucous  membrane  than  for  any  hope  of  an  undefined  influence  over 
the  general  disease.  Dr.  Jacobi  confesses  that  he  is  less  sceptical  as  to 
the  action  of  mercurials  than  he  was  a  quarter  of  a  century  ago  ('  Treatise 


DENUTKIENTS.  127 

on  Diphtheria,"  1880),  and  he  recommends  ten  or  twelve  minims  of  the 
oleate  to  be  rubbed  along  the  inside  of  the  arms  or  elsewhere  when  the 
surface  becomes  irritated,  every  hour  or  two,  or  else  hypodermic  injections 
of  perchloride,  which  act  very  promptly.  More  recently,  at  the  New  York 
Academy  of  Medicine  {Medical  Record,  May  31,  1881),  Dr.  Jacobi  ad- 
vised the  use  of  the  sublimate  in  pseudo-membranous  affections  of  the 
respiratory  organs,  to  be  given  in  frequent  doses,  so  as  to  bring  the 
system  under  its  influence  speedily.  He  said  that  infants  of  tender  age 
could  bear  half  a  grain  a  day  for  many  days  in  succession,  and  he  thought 
that  the  exudation  might  by  this  method  be  prevented  from  extending 
to  the  larynx.  Salivation  and  gastro-intestinal  disturbances  are  not 
frequent,  and  if  the  sublimate  should  not  be  well  tolerated  he  would  use 
inunction.  As  a  rule,  the  administration  of  mercury  is  less  objectionable 
the  vounger  the  patient.  Doses  of  one-sixtieth  to  one-twenty-fifth  of  a 
grain  may  be  given  every  hour,  and  continued  from  one  to  five  or  six 
days. 

Others,  however,  who  have  tried  this  remedy  are  content  with  giving 
it  in  much  less  doses,  e.g.,  -j-^-g-  grain  dissolved  in  water,  every  hour,  con- 
tinuing it_  both  night  and  day,  unless  the  patient  sleeps.  Others,  again, 
use  a  spray  every  half  hour  or  hour,  some  of  which,  of  course,  passes 
into  the  system.  A  quarter  or  one-eighth  of  a  grain  to  the  ounce  of 
water  (with  a  drachm  of  glycerine)  will  be  strong  enough  for  this  purpose, 
aTid  give  a  dose  of  -^\^  grain  in  half  a  drachm  or  drachm  respectively,  of 
which  a  part  will  be  lost. 

Baerensprung's  albuminate  or  Bamberger's  peptonate  may,  perhaps, 
be  substituted  for  the  perchloride  with  advantage,  for  they  are  even  less 
liable  to  induce  stomatitis  ;  they  maybe  used  hypodermically, or  if  taken 
by  the  stomach  scarcely  ever  disturb  it.  At  the  same  time  the  sublimate 
is  an  exceedingly  powerful  antiseptic.  Bacteria  are  killed  by  it  in  dilu- 
tions of  one  in  twenty  thousand,  according  to  Buchholtz,  and  some  say 
one  in  three  hundred  thousand  ;  at  any  rate,  it  is  much  more  powerful 
than  the  other  antiseptics  which  have  been  recommended,  and  may  often 
be  given  more  freely  than  is  generally  supposed.  My  experience  cor- 
roborates those  who  have  stated  that  the  perchloride  may  be  given  in 
larger  doses,  or  rather  that  the  doses  may  be  more  frequently  repeated 
without  danger  in  various  diseases.  It  is  probable  that  this  salt,  or  at 
any  rate  the  albuminate  or  peptonate,  passes  into  the  blood  unchanged 
and  is  not  deleterious  to  the  corpuscles.  An  infant  under  one  year  can 
take  one-fiftieth  of  a  grain  well  diluted  every  hour  without  obviously 
injuring  the  corpuscles,  but  no  doubt  smaller  doses  will  usually  be 
sufficient,  y^  or  even  ^-|-q  grain,  and  it  is  perhaps  better  to  proceed 
cautiously  except  in  very  urgent  cases. 

In  Pneumonia. — The  old  treatment  by  mercury  and  antimony  in  the 
early  state  is  now  obsolete,  but  it  is  sometimes   resorted  to  at  a  later 


128  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

period,  when  there  is  secondary  fever  and  purulent  degeneration  is  ap- 
prehended, or  wlien  removal  of  consolidation  is  delayed.  In  pleuro- 
pneumonia or  in  chronic  interstitial  pneumonia  mild  preparations  are 
still  sometimes  resorted  to,  and  strumous  or  other  deposits  are  said  to 
disappear  under  its  influence.  The  question  arises  whether  some  of 
these  deposits  may  have  been  syphilitic.  The  perchloride,  albuminate,  or 
peptonade,  or  else  the  iodide,  are  the  best  preparations  in  such  cases,  but 
I  certainly  prefer  even  to  these  small  quantities  of  iodide  of  potassium 
or  sodium.  A  blister  is  often  effectual  in  these  cases,  and  may  be  dressed 
with  mercurial  ointment. 

In  Pleurisy. — Mercury  is  still  employed  and  has  the  sanction  of  Dr. 
Walshe.  AVhen  there  is  considerable  effusion  modern  practice  seems 
rather  to  trust  to  the  aspirator,  but  when  it  is  very  slight  the  stimulat- 
ing effect  of  mercury  on  the  absorbents  is  sometimes  relied  upon  ;  even 
here,  however,  the  simplest  measures  are  perhaps  equally  effective,  and 
certainly  in  the  early  stages  there  is  no  call  for  mercury  ;  the  fever  can 
be  restrained  by  aconite  or  salines,  and  pain,  if  severe,  allayed  by 
morphia,  while  rest,  mild  counter-irritants,  and  appropriate  diet  suffice  to 
cope  with  slight  cases,  and  severe  ones  cannot  be  arrested  by  the  gentle 
mercurial  treatment,  which  only  is  recommended. 

Emetics. — These  very  ancient  remedies  have  not  yet  gone  to  the 
limbo  of  oblivion,  as  it  is  sometimes  necessary  to  empty  the  stomach  of 
poison  or  food,  but  otherwise  they  are  not  very  frequently  used  ;  they 
may  be  divided  into  the  direct^  which  act  upon  the  stomach,  and  the  in- 
direct, which  act  through  the  system.  Vomiting  may  occur  in  conse- 
quence of  a  mental  impression,  or  from  a  disordered  condition  of  the 
blood  impressing  the  nervous  system,  producing  central  emesis.  On  the 
other  hand,  peripheral  irritation  in  the  stomach  or  some  other  organ  may 
give  rise  to  excentric  or  reflex  vomiting.  Some  emetics  act  in  both 
ways,  e.g.,  antimony,  ipecacuanha,  and  apomorphia,  though  some  doubt 
has  been  cast  on  the  views  generally  held.  Thus  the  purging  which  fol- 
lows the  use  of  antimony  is  certainly  connected  with  the  elimination  of 
the  poison  through  the  intestinal  membrane  ;  and  it  has  been  asserted 
that  the  same  thing  occurs  in  the  gastric  membrane  when  the  antimony 
is  injected  into  the  blood.  So,  too,  Dr.  D'Ornellas,'  having  injected 
emetin  into  the  veins  of  animals,  found  the  alkaloid  eliminated  by  the 
gastric  mucous  membrane.  Antimony  depresses  the  circulation  intensely, 
ipecacuanha  not  much,  while  ammonia  is  a  stimulant.  We  do  not  em- 
ploy emetics  in  respiratory  diseases  for  the  sake  of  depleting,  but  rather 
for  the  effects  of  the  vomiting,  and  the  acts  associated  with  it.  These 
complex,  co-ordinated  acts  are  said  to  be  governed  by  a  centre  in  the 


'  D'Ornellas  :    Du  Yomissemeiit ;  contribution  a  I'L-tude   de  I'aciiou  des  vomitifs. 
1873. 


DENUTKIENTS.  129 

medulla,  so  that  emesis  may  be  produced  by  any  powerful  stimulant  of 
this  centre,  but  the  respiratory  centre  must  also  be  engaged,  to  which 
may  be  attributed  the  expiratory  movements,  such  as  sneezing  and 
coughing,  which  so  frequently  announce  the  app-oaching  vomiting;  then 
there  is  a  further,  more  powerful  expiratory  effort  during  the  emesis, 
when  the  viscera  are  forcibly  compressed  and  the  glottis  closed.  Again 
at  the  close  there  is  a  further  expiratory  effort,  so  that  the  moment  the 
glottis  opens  there  is  a  blast  of  air  outward  which  would  prevent  the 
entrance  of  particles  into  the  larynx.  So  in  emesis,  tlie  nasal  passage  is 
usually  closed  as  in  deglutition,  though  sometimes  the  ascending  stream 
either  forces  its  way  or  takes  the  muscles  by  surprise.  There  is  also 
generally  increased  secretion  of  bronchial  mucus,  which  is  carried  upward 
by  the  air-current.  These  movements  explain  the  value  of  the  act  of 
vomiting  in  emptying  the  air-passages.  The  abdomen  is  also  compressed, 
by  which  the  gall-bladder  is  emptied,  and  sometimes  the  bile  regurgitates 
into  the  stomach  and  is  vomited  ;  there  is  usually  a  free  flow  of  saliva. 
The  cardiac  and  vascular  centres  are  depressed,  hence  we  observe  a 
feeling  of  faintness,  and  sometimes  syncope  occurs  ;  the  motor  centres 
are  lowered,  and  so  there  is  a  feeling  of  prostration.  Profuse  sweating 
is  not  uncommon,  and  this,  too,  is  referred  by  many  to  a  sweat-centre  in 
the  medulla. 

The  simple  direct  irritant  emetics  act  without  being  absorbed,  but  the 
others  require  to  find  their  way  into  the  system.  The  irritants  are  there- 
fore mostly  more  prompt,  e.g.,  mustard  is  both  efficient  and  quick,  and 
has  also  the  advantage  of  being  always  at  hand  ;  it  is  frequently  success- 
ful even  in  torpor  of  the  stomach,  as  in  narcotic  poisoning.  Antimony 
and  ipecacuanha  act  both  as  direct  and  indirect  emetics  and  are  of 
special  value  in  respiratory  diseases.  Both  produce  nausea  and  depression, 
and  the  former  great  muscular  relaxation.  Apomorphia  also  acts  both 
ways,  but  produces  little,  if  any  depression  ;  it  is  exceedingly  useful 
where  time  is  of  importance,  as  a  hypodermic  injection  is  rapidly  effec- 
tive ;  its  only  disadvantage  is  that  the  solution  does  not  keep,  but  gela- 
tine disks  meet  the  difficulty. 

Chouppe  tells  us  '  that  ajjomorphia  or  tartar  emetic  injected  into  the 
veins  of  animals  excited  vomiting  as  freely  after  section  of  the  pneumo- 
gastric  as  before,  but  this  was  not  the  case  with  emetin,  from  which  he 
concluded  that  this  last  acted  through  the  peripheral  terminations  of  the 
nerve  while  the  other  two  affected  the  centre  directly.  This  view  seems 
to  be  corroborated  by  Dr.  Duckworth's  experiments. 

Passing  over  other  indications  for  emetics,  they  are  sometimes  used 
for  dislodging  foreign  bodies  from  the  throat,  for  which  purpose  apomor- 
phia hypodermically  is  most  appropriate.      In   croup  and  diphtheria  they 

'  Recherches  Thcrapeutiques  et  Physiologiques  sur  I'lpeca.     1875. 
9 


130  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

are  used  to  remove  the  exudation  from  the  air-passages,  and  in  this  way 
they  often  greatly  relieve  the  respiration,  just  as  they  also  do  in  bron- 
chitis wiien  the  passages  are  clogged  with  tenacious  sputa.  It  has  been 
supposed  that  they  also  restrain  the  exudative  prooess,  and  to  obtain  this 
effect,  nauseating  doses  are  sometimes  administered  during  the  intervals 
between  which  emetics  are  given.  It  will  be  found,  however,  that  such 
severe  treatment  is  apt  to  be  dangerous,  and  we  should  look  only  to  their 
power  to  mechanically  remove  the  exudation  as  an  indication  for  their 
use  in  such  cases. 

In  suffocative  bronchitis  an  emetic  will  often  produce  relief  when  all 
other  measures  seem  hopeless.  Ipecacuanha  is  the  most  suitable  for  this 
purpose.  A  large  quantity  of  mucus  is  evacuated,  the  intense  dyspnoea 
gives  way  to  quiet  respiration,  and  the  distress  and  anxiety  subsides  into 
quiet,  refreshing  sleep,  the  cyanosed  face  becoming  natural.  It  is  true 
that  the  secretion  will  again  accumulate,  but  much  has  been  gained  and 
the  danger  of  asphyxia  is  at  least  postponed,  and  sometimes  quite  re- 
moved ;  nutrients  and  ammonia  may  then  be  administered.  In  phthisis 
there  is  more  danger  of  exhaustion.  Dr.  Paris  ("  Pharmacologia,"  1843) 
mentions  a  case  in  which  an  emetic  produced  fatal  syncope  in  a  patient 
to  whom  it  was  given  in  the  hope  of  dislodging  the  pus  which  embar- 
rassed the  respiration.  Hippocrates  recognized  this  danger,  and  said 
consumptives  ought  not  to  be  purged  by  emetics  ("  Aphorisms,"  iv.,  8). 
Emetics  used  to  be  frequently  employed  to  induce  relaxation  in  spas- 
modic affections  of  the  respiratory  system.  In  such  cases  the  condition 
of  nausea  is  indicated,  and  therefore  we  may  use  successive  small  doses 
at  frequent  intervals  until  vomiting  ensues,  or  even  short  of  it.  For  this 
purpose  ipecac  is  the  mildest  and  much  the  safest  for  children  and  old 
people.  The  plan  of  giving  successive  nauseating  doses  until  vomiting 
takes  place  has  often  been  used  to  cut  short  a  cold,  but  many  patients 
consider  the  remedy  worse  than  the  disease.  It  is  not  the  act  of  vomit- 
ing which  is  here  useful,  but  rather  the  free  bronchial  secretion  which  is 
hastened,  and  the  lessening  of  arterial  action  which  is  produced.  It  is 
not  emesis  but  nausea  which  is  needed. 

In  acute  laryngitis,  tracheitis,  and  even  bronchitis,  this  was  once  the 
favorite  method  of  treatment,  but  it  has  been  largely  displaced  by  milder, 
or  perhaps  more  direct  methods,  especially  since  the  laryngoscope  has 
enabled  us  to  watch  the  local  conditions. 

Nauseants. — Still  smaller  doses  of  the  indirect  emetics,  antimony  and 
ipecacuanha,  may  be  also  employed  in  order  to  set  up  a  moderate  degree 
of  nausea,  not  culminating  in  vomiting.  This  condition  may  be  excited 
with  benefit  in  many  respiratory  diseases,  especially  when  fever  runs 
high.  The  relaxation,  the  depression  of  the  whole  system,  more  particu- 
larly of  the  cardiac  centre,  which  are  produced,  all  help,  and  show  how  our 
predecessors  studied  clinically  and  knew  that  these  remedies  would   re- 


DENUTEIENTS.  131 

duce  arterial  action  and  moderate  inflammation.  No  wonder,  then,  that 
they  were  freely  resorted  to  in  the  absence  of  some  other  remedies  which 
are  now  available.  More  might  now  be  made  of  them  if  more  attention 
were  given  to  dosage. 

Antimony. — Tartar  emetic  depresses,  sometimes  even  to  a  dangerous 
degree,  but  that  depression  is  the  key  to  its  use.  To  obtain  its  contra- 
stimulant  effect,  as  it  was  called  by  Rasori,  we  do  not  require  the  massive 
doses  he  employed.  Small  medicinal  doses  repeated  at  intervals  lower 
the  pulse  and  increase  the  perspiration — act  as  diaphoretics  and  febri- 
fuges ;  at  the  same  time  the  respiratory  mucous  membrane  is  provoked  to 
increased  secretion,  as  is  also  that  of  the  alimentary  canal — but  this  last 
effect  is  not  usually  noticeable  in  doses  too  small  to  nauseate.  As  soon, 
however,  as  nausea  is  set  up  there  is  liability  to  purging  also,  unless 
some  remedies  to  prevent  this  have  been  combined  with  it.  At  this 
stage  the  pulse  falls  considerably,  the  heart  is  much  depressed,  and 
fainting  may  occur  ;  the  antimony  seeming  to  act  directly  on  the  sub- 
stance of  the  heart  as  well  as  on  the  muscular  and  nervous  system.  As 
the  cardiac  contractions  grow  less  frequent  and  less  forcible  they  may 
become  irregular,  and  in  cases  of  slow  poisoning  the  heart  is  arrested  in 
diastole,  its  irritability  after  death  being  nearly  or  quite  lost.  Experi- 
menters tell  us  that  antimony  does  not  alter  the  temperature.  Dr.  Ringer 
gave  half  a  grain  every  ten  minutes  to  a  strong,  healthy  man  for  nearly 
seven  hours,  inducing  great  nausea  and  vomiting  with  profuse  perspira- 
tion, but  during  the  whole  time  his  temperature  remained  remarkably  con- 
stant, varying  not  more  than  0A°  Fahr.  ;  as  great  a  deviation  may  con- 
stantly be  observed  in  health.  Whatever  may  be  the  case  in  health,  a 
febrile  temperature  is  easily  reduced  by  even  small  doses,  and  this  effect 
may  often  be  obtained  without  exciting  nausea  if  the  doses  and  the  inter- 
vals at  which  they  are  repeated  be  carefully  regulated.  After  too  large  or 
too  frequent  doses,  not  only  nausea  but  even  vomiting  may  ensue,  and 
this  sometimes  occurs  against  our  wishes,  on  account  of  the  unusual  sus- 
ceptibility of  the  patient  ;  but  generally  we  can  obtain  sufficient  depres- 
sion of  the  circulation,  fall  of  the  pulse,  free  perspiration,  and  bronchial 
secretion  without  emesis. 

Antimony  acts  throughout  the  gastro-pulmonary  mucous  membrane. 
It  irritates  the  stomach  and  bowels,  and  though  no  special  lesion  may  be 
found  on  this  membrane  after  poisoning,  there  are  always  indications  of 
severe  inflammation.  The  vomiting  and  the  purging  are  probably  con- 
nected with  elimination,  which  is  effected  through  the  mucous  membrane 
as  well  as  through  the  kidneys.  It  possesses  a  special  action  on  the  bron- 
chial membrane,  even  in  moderate  doses,  as  all  clinical  experience  proves  ; 
this  is  why  it  is  so  effective  in  the  first  stage  of  bronchitis,  but  as  soon  as 
free  secretion  takes  place  its  local  work  is  accomplished,  though,  of 
course,  if  continued  it  would  still   be  depressant  and  diaphoretic    as  well 


132  THERAPEUTICS    OF   THE    EESPIRATORY    PASSAGES. 

as  expectorant.  It  must,  however,  be  but  rarely  advisable  to  continue  it 
after  the  secretion  is  established,  as  there  is  no  doubt  that  it  tends  to 
weaken  the  respiratory  movements  as  well  as  the  circulation  whenever  it 
is  continued  too  long'.  It  is  therefore  desirable  to  obtain  its  good  effect 
in  the  early  stage  of  bronchial  inflammation,  and  then  to  replace  it  by 
other  remedies.  Minute  doses  can  be  added  with  advantage  to  many 
febrifuges — that  is  to  say,  in  sthenic  cases. 

In  pneumonia,  as  a  powerful  cardiac  depressant,  nauseant  doses  were 
for  a  long  time  in  favor.  Rasori  and  the  Italian  school  used  much  larger 
quantities,  but  the  system  is  not  without  danger.  In  this  country  we  are 
content  with  quantities  which  suffice  to  abate  the  arterial  excitement  and 
produce  perspiration,  and  perhaps  excite  slight  nausea.  Laennec,  Trous- 
seau, and  others  used  one-grain  doses,  Stokes,  Watson,  and  Billing  much 
less  ;  and  it  may  be  said  that  the  minute  doses  we  have  indicated  are 
sufficient,  and  even  these  are  at  present  seldom  resorted  to  in  this  dis- 
ease. In  bronchitis  attacking  young  robust  adults,  the  remedy  seems 
more  distinctly  indicated  on  account  of  its  valuable  effect  upon  the  mem- 
brane. While  it  abates  pyrexia  and  lowers  the  blood-tension,  it  brings 
about  expectoration  and  relieves  the  oppression  and  dyspnoea,  and  when 
the  cough  is  severe  morphia  or  belladonna  can  be  added  to  it.  In  the 
capillary  bronchitis  of  children,  with  a  pulse  of  130  to  140,  temperature 
101°  to  103°  F.,  intense  oppression  of  the  breathing,  dusky  face  and 
clammy  skin,  restlessness,  delirium  or  coma,  minute  doses  have  sometimes 
proved  remarkably  efficacious,  but  the  remedy  should  be  withdrawn  as 
soon  as  the  effect  is  produced.  One-hundredth  of  a  grain  every  two  or 
three  hours  will  suffice  for  such  a  purpose.  In  croup  nauseant  doses 
have  sometimes  been  employed,  but  are  not  required  ;  if  an  emetic  is 
needed  to  act  mechanically,  let  it  be  given,  but  the  practice  of  giving 
nauseants  only  debilitates  the  little  patients,  and  should  not  be  resorted 
to  even  to  abate  fever,  which  can  be  controlled  by  other  remedies.  In 
spasmodic  croup  nauseants  are  still  less  admissible. 

Antimony  is  contra-indicated  in  old  age  and  in  infancy.  In  children 
it  is  likely  to  lead  to  collapse,  and  in  elderly  persons  it  may  do  this, 
though  it  often  expends  its  energies  on  the  stomach.  Both  young  and 
old  are  very  susceptible  to  its  influence  and  likely  to  be  too  much  weak- 
ened. In  hernia,  aneurism,  or  other  diseases  of  the  circulatory  system,  in 
cerebral  congestion,  in  gastric  irritation,  in  pregnancy,  and  wherever  the 
act  of  vomiting  is  likely  to  be  injurious,  nauseants  are  to  be  avoided. 

Ipecacuanha  acts  both  on  the  digestive  and  respiratory  tract,  but 
does  not  produce  much  effect  on  the  circulation  unless  nausea  be  pro- 
duced, neither  does  it  reduce  the  temperature.  In  poisonous  quanti- 
ties it  affects  the  lungs,  pulmonary  lesions  having  been  observed  after 
death.  By  it  we  can  stimulate  the  bronchial  mucous  membrane  and  per- 
haps also  the  skin,  even  in  small  doses,  certainly  in  nauseant  ones.     The 


DENUTRIENTS.  133 

effect  on  the  alimentary  mucous  membrane  may  be  due  to  its  being  elim- 
inated there,  as  D'Ornellas  '  and  Pecholier''  found  emetin  escaped  by  the 
stomach  and  bowels  when  it  was  injected  into  the  circulation  or  the  cel- 
lular tissue.  As  a  nauseant  it  is  depressant,  but  otherwise  does  not 
seem  to  affect  the  circulation,  though  Dr.  Duckworth  ^  produced  cardiac 
paralysis  by  injecting  emetin  direct  into  the  circulation.  From  half  a 
grain  to  a  grain  every  two,  three,  or  four  hours  is  sufficient  for  nau- 
seating. 

Some  persons  are  peculiarly  susceptible  to  the  influence  of  ipecacu- 
anha, the  smallest  doses  producing  violent  disturbances  of  the  respiratory 
system.  A  sort  of  spurious  influenza,  or  bronchitis,  or  asthma,  or  hay- 
fever  may  be  set  up,  according  to  the  idiosyncrasy  of  the  patient  ;  the 
mucous  membrane  of  the  conjunctivae  perhaps  participates  in  the  affec- 
tion. Sneezing,  itching,  or  irritation  of  the  nose,  succeeded  by  a  watery 
tlischarge,  frontal  pain,  cough,  and  oppression  of  the  breathing,  may  be 
produced.  It  is  not  always  necessary  for  the  drug  to  be  swallowed  to 
induce  these  attacks.  Many  years  ago  I  knew  a  lady,  the  sister  of  a 
medical  man,  who  suffered  from  violent  asthmatic  attacks  whenever 
ipecacuanha  was  powdered  in  his  surgery,  although  she  remained  in  an- 
other room. 

As  a  nauseant  ipecacuanha  may  be  used  instead  of  antimony  when  it 
is  desirable  to  avoid  the  depressing  effects  of  the  latter.  As  soon  as  the 
nausea  comes  on  gentle  diaphoresis  ensues,  and  prior  to  this  there  is 
often  increased  bronchial  secretion.  To  obtain  this  last  result  it  is  not 
needful  to  produce  nausea,  but  with  regard  to  the  skin  there  is  some  dif- 
ference of  opinion  ;  if,  however,  a  little  aconite  be  added,  to  act  on  the 
circulation,  the  diaphoretic  effect  will  be  marked.  To  the  action  on  the 
alimentary  mucous  membrane  we  may  attribute  the  favor  accorded  to 
this  remedy  in  diseases  of  that  tissue,  and  perhaps  the  frequency  with 
which  small  doses  are  found  useful  adjuvants  to  aperient  pills.  The 
effect  on  the  bronchial  mucous  membrane  is  the  most  important  of  all, 
but  will  be  considered  further  on  among  the  expectorants. 

DIAPHORETICS. 

As  we  have  seen,  the  nauseants  lower  arterial  action.  Antimony  may 
possibly  act  locally  on  the  skin,  as  doubtless  do  some  other  diaphoretics, 
most  of  which  have  other  actions  besides  that  of  promoting  perspiration. 
No  doubt  nausea  leads  to  sweating,  but  antimony  certainly,  and  other 
nauseants  probably,  may  be  made  to   produce  perspiration  without  dis-, 

'  D'Ornellas  :  Op.  cit. 

-  Pccholier :  Recherches  experimentales  sur  Taction  physiologique  de  I'lpecacu- 
anta.     1862. 

'  St.  Bartholomew's  Hospital  Eeports,  vol.  vil. 


134  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

turbing  the  stomach  ;  but  as  this  group  of  remedies  is  most  useful  in 
respiratory  diseases,  it  will  be  further  considered  with  expectorants. 
Under  the  use  of  the  nauseants  the  skin  becomes  relaxed,  much  as  it  is 
in  collapse,  or  in  a  much  milder  degree,  as  it  is  in  sleep,  when  we  know 
there  is  a  greater  disposition  to  perspire,  to  which,  perhaps,  may  be  at- 
tributed the  fact  that  colliquative  sweats  mostly  occur  during  sleep. 
They  may  also  act  by  reducing  the  circulation,  by  which  they  serve  as 
antiphlogistics  and  febrifuges,  for  in  pyrexia  the  secretions  are  mostly 
diminished  and  the  skin  is  very  dry,  its  function  failing  from  excess  of 
vascular  action.  In  such  cases  whatever  restores  the  balance  liberates 
the  perspiration,  and  so  not  only  nauseants,  but  all  febrifuges,  all  refrig- 
erants, even  such  salines  as  are  usually  diuretics  take  a  place  among 
diaphoretics.  These  two  classes  continually  interchange,  for  the  skin 
and  kidneys  supplement  each  other,  and  whether  a  remedy  stimulate  the 
action  of  one  or  the  other  often  depends  entirely  on  whether  the  surface 
be  kept  warm  or  not.  When  a  patient  is  in  bed  or  keeps  his  room,  or 
when  the  weather  is  warm,  a  medicine  may  act  as  a  diaphoretic  which, 
when  he  is  walking  about,  or  in  cold  weather,  will  produce  diuresis. 

Again,  vascular  fulness  promotes  secretion,  so  that  drinking  an  extra 
quantity  of  fluid  produces  diaphoresis  while  the  surface  is  kept  warm, 
but  in  an  opposite  state  diuresis  occurs.  Thus  all  beverages,  especially 
when  taken  warm,  may  be  grouj)ed  as  diluent  diaphoretics.  Perhaps 
hot  drinks  also  act  reflexly  on  the  sweat-centre,  for  we  may  often  ob- 
serve that  almost  immediately  after  taking  a  cup  of  tea  or  any  hot  liquid 
perspiration  will  break  out. 

External  heat.is  a  more  powerful,  and  perhaps  more  direct  diapho- 
retic, the  influence  being  conveyed  through  the  afferent  thermic  nerves. 
But  here  the  vascular  system  is  obviously  also  concerned,  the  blood 
being  attracted  to  the  surface  and  thus  vascular  fulness  induced.  The 
heat  may  be  moist  or  dry,  as  in  hot  baths,  vapor  baths,  the  lamp  bath, 
the  Turkish  bath,  etc.  Friction,  exercise,  and  other  influences  which 
bring  the  blood  to  the  surface  also  produce  perspiration.  On  the  other 
hand,  sudden  cold  may  do  this,  but  that  is  only  by  the  reaction  which  is 
set  up.  In  the  same  way  a  draught  of  cold  water  instead  of  hot  may 
bring  on  a  sweat.  Alcohol,  by  dilating  the  cutaneous  capillaries  will  act 
as  a  diaphoretic,  especially  when  taken  liot,  but  perhaps  some  of  this 
effect  may  be  from  its  acting  on  the  centre  like  narcotics,  or  rather  on 
both  centre  and  periphery,  as  well  as  by  sending  at  first  a  more  copious 
supply  of  blood  to  the  vessels  of  the  skin. 

Another  group  of  diaphoretics  is  supposed  to  stimulate  the  centre 
for  sweat.  Opium  is  one  of  these,  but  its  diaphoretic  action  is  by  no 
means  the  most  important  indication  for  its  use.  It  will  be  considered 
at  length  among  the  narcotics.  Jaborandi  and  its  alkaloid,  pilocar- 
pine, are  supposed  to  stimulate  not  only  the  centre  but  the  end-organs  of 


DETTUTKIENTS.  X35 

the  nerve  and  the  sweat-glands.  Perhaps  other  members  of  this  group 
do  the  same.  After  entering  the  circulation  and  acting  upon  the  centre 
they  may  be  partially  eliminated  through  the  skin,  and,  acting  as  elimi- 
nants  always  do,  stimulate  the  organ  through  which  they  are  removed. 

Diaphoretics  are  employed  to  restore  secretion  when  arrested  and  to 
increase  it  when  diminished,  to  eliminate  from  the  blood  liquid  and 
even  solid  noxious  matters,  to  moderate  the  circulation,  to  determine 
to  the  surface,  to  favor  absorption,  to  arrest  incipient  disease,  as  ca- 
tarrh, rheumatism,  etc.  Their  action  may  be  promoted  by  previous  vene- 
section, which,  however,  is  nowadays  scarcely  ever  resorted  to  ;  by  tlie 
administration  of  diluents,  except  after  the  nauseants,  when  warm  fluids 
would  be  likely  to  excite  vomiting.  When  the  temperature  of  the  pa- 
tient is  high,  cold  diluents  may  be  employed  ;  otherwise  cold  drinks 
should  be  avoided,  as  they  are  apt  to  determine  to  the  kidneys,  and  we 
know  that  the  action  is  retarded  by  diuretics,  by  purgatives,  and  by  ex- 
posure to  cold.  From  the  last  statement,  as  well  as  from  what  has  pre- 
ceded, a  cardinal  rule  may  b6  deduced  :  to  keep  the  patient  warm,  both 
by  flannel  clothing  and  by  the  maintenance  of  a  suitable  temperature  in 
the  room.     It  is  especially  desirable  to  keep  the  feet  warm. 

The  amount  of  perspiration  produced  is  by  no  means  the  measure  of 
the  benefit  obtained.  A  single  full  free  perspiration  will  indeed  some- 
times arrest  a  catarrh,  but  to  make  the  quantity  of  liquid  removed  the 
chief  object  is  a  decided  error.  Very  often  the  good  effect  is  due  rather 
to  the  change  iu  the  circulation  than  to  the  increased  secretion. 

It  is  usual  to  administer  diaphoretics  at  bedtime,  and  the  practice  is 
convenient,  as  we  thereby  secure  warmth  and  rest  for  some  hours  after 
the  dose.  But  when  the  patient  is  confined  to  his  bed  this  does  not  ap- 
ply, and  morning  is  then  an  appropriate  time,  for  after  the  sleep  the 
skin  is  in  the  condition  of  relaxation,  which  predisposes  it  to  diaphoresis. 
This  is  well  understood  by  many  balneologists,  who  make  their  patients 
take  a  course  of  warm  mineral  baths  in  the  morning  and  prescribe  rest 
in  bed  after  the  bath  for  a  time  sufficient  to  secure  a  free  perspiration. 
Powerful  stimulant  diaphoretics  should  not  be  resorted  to  in  inflamma- 
tory and  febrile  diseases.  In  affections  of  the  respiratory  tract  the 
nauseants  perhaps  take  the  first  place,  then  the  salines  and  refrigerants. 
To  arrest  a  catarrh  a  single  copious  sweat  will  often  suffice,  and  this 
may  be  secured  by  a  hot  bath  or,  where  attainable,  by  the  Turkish  bath, 
but  this  is  rather  contra-indicated  where  there  is  much  febrile  excite- 
ment, for  should  there  be  a  disposition  to  pulmonary  congestion  or 
cedema  it  would  tend  rather  to  precipitate  an  attack — the  hot,  dry  air 
stimulating  the  respiratory  system.  Should  dyspncea  or  any  consider- 
able disturbance  of  respiration  occur  in  the  Turkish  bath  in  a  person 
predisposed  to  pulmonary  attacks,  it  would  be  safer  at  once  to  quit  the 
hot  room. 


136  THERAPEUTICS    OF    THE    RESPIRATOKY   PASSAGES. 

Xauseaxt  Diaphoretics. — There  is  no  doubt  about  the  power  of 
antimony  to  promote  perspiration,  an  effect  Avhich  can  be  obtained 
■without  inducing  nausea,  ^yith  regard  to  ipecacuanha,  this  is  less  gen- 
erally admitted,  and  many  believe  that  it  is  a  sudorific  only  when  it  ex- 
cites nausea.  It  seems  to  me,  however,  that  it  tends  to  keep  the  skin  soft 
and  moist,  though  it  does  not  produce  a  full  sensible  perspiration  in 
doses  insufficient  to  nauseate.  To  obtain  a  single  copious  perspiration 
Dover's  powder  is  mostly  effectual,  but  here  the  opium  may  be  regarded 
as  the  principal  sudorific,  though  the  ipecacuanha  doubtless  assists  its 
action.  The  compound  is  therefore  one  of  the  best  sedative  sudorifics, 
but  thoug'h  it  may  often  be  employed  for  this  purpose  it  is  to  be  avoided 
whenever  narcotics  are  contra-indicated. 

Salixe  Diaphoretics. — The  most  commonly  used  of  this  group  is  the 
ammonium  acetate,  a  solution  of  which  was  introduced  by  Boerhaave  in 
1732,  Soon  afterward  one  Minderer  or  Mindererus  employed  it,  and  it 
has  since  been  known  after  him  as  Mindererus'  spirit.  It  is  only  a  gentle 
diaphoretic,  producing  no  other  sensible  effect,  and  to  secure  this  the 
surface  must  be  kept  warm  ;  otherwise,  it  may  act  as  a  diuretic.  Though 
in  almost  universal  use,  many  have  little  faith  in  it.  Cullen  tells  us  he 
had  seen  four  ounces  of  it  taken,  and  shortly  afterward  the  same  dose 
repeated  without  producing  any  sensible  effect.  Perhaps  the  solution 
employed  was  not  of  proper  strength,  for  at  different  periods  various 
methods  of  preparation  have  been  resorted  to,  and  even  when  freshly 
made  in  small  quantities,  unless  due  care  be  taken,  the  results  will  differ. 
Sometimes  the  solution  has  been  left  with  an  acid  reaction,  sometimes 
the  reverse,  and  it  is  obvious  that  the  effects  will  be  altogether  different. 
The  solution  of  the  new  United  States  Pharmacopoeia  contains  about 
7.6  of  the  acetate,  which  is  about  1.6  stronger  than  the  earlier  editions, 
but  very  often,  from  carelessness,  the  proper  strength  has  not  been  em- 
ployed. A  well-prepared  neutral  solution  may  be  rendered  acid  or  al- 
kaline at  will,  or  the  solution  may  be  given  in  an  effervescing  mixture. 
Citrate  of  ammonium  has  been  lately  used  as  a  substitute  for  the  acetate. 
Citrate  of  potash  is  also  used  as  a  basis  for  fever  mixtures  and  is  also 
most  agreeably  given  in  an  effervescing  form.  It  is,  however,  like  other 
potash  salts,  more  likely  to  act  as  a  diuretic  than  the  ammonium  salt. 

Spiritiis  cetheris  nitrosi  is  often  used  in  conjunction  with  liquor 
ammonias  acetatis,  and  has  for  hundreds  of  years  been  regarded  as  a 
valuable  diaphoretic,  as  well  as  diuretic.  Raymond  Lully  mentions  it  in 
the  thirteenth  century,  and  Basil  Valentine  in  the  fifteenth  describes  an 
improved  method  of  preparing  it.  Sweet  spirits  of  nitre  is  now  in  daily 
use  by  the  public,  as  well  as  by  the  profession,  and  yet  some  have  little 
faith  in  it.  Perhaps  this  is  partly  due  to  the  uncertainty  of  the  prepa- 
ration, which  is  also  apt  to  deteriorate  by  keeping.  The  British  Pharma- 
copoeia spirit  is  only  about  half  the  strength   of  the  United  States  Phar- 


DENUTEIENTS.  137 

macopceia.  It  owes  its  activity  to  nitrite  of  ethyl,  of  which  the  British 
Pharmacopoeia  ought  to  contain  two  per  cent.,  but  many  specimens  con- 
tain less.  There  is  no  doubt  that  when  inhaled  the  vapor  may  destroy 
life.  Christison  mentions  that  a  druggist's  servant  was  found  dead  in 
lier  bed  one  morning,  after  sleeping-  in  a  room  in  which  a  three-gallon 
jar  had  been  accidentally  broken. 

Owing  its  activity  to  ethyl  nitrite,  we  might  suppose  that  the  effects 
of  spirits  of  nitre  would  resemble  those  of  other  nitrites,  and  this  has 
lately  been  shown  to  be  the  case,  particularly  by  Dr.  Hay  and  Professor 
D.  J.  Leech  {Practitioner,  1883).  Comparing  it  with  nitrite  of  amyl,  it 
is  indeed  a  feeble  remedy,  but  possesses  similar  qualities.  It  unques- 
tionably lowers  arterial  tension,  quickens  the  beat  of  the  heart,  and  di- 
lates the  peripheral  vessels,  and  tiiis  is  how  it  acts  as  a  diaphoretic  and 
a  diuretic.  In  the  same  way  the  uncertainty  in  its  action,  which  has 
often  been  complained  of,  may  be  explained.  When  the  arterial  tension 
is  already  low  it  is  not  a  suitable  remedy.  We  may  presume  that  it 
causes  diuresis  by  relaxing  the  renal  vessels,  but  if  the  tension  should  be 
already  low  and  the  venous  side  of  the  circulation  want  relief,  as  is  often 
the  case  in  cardiac  dropsy,  then  it  would  naturally  fail,  and  curiously 
enough  it  is  in  cases  of  this  kind  in  which  its  uncertainty  has  been  most 
complained  of.  In  the  same  way  dilatation  of  the  cutaneous  vessels 
leads  to  perspiration,  but  that  is  only  one  factor  in  the  production  of 
diaphoresis,  Tiie  use  of  the  remedy  is,  then,  to  reduce  tension,  and  for 
this  reason,  perhaps,  large  doses  might  be  employed  instead  of  more  pow- 
erful agents,  such  as  nitrite  of  amyl,  nitro-glycerine,  nitrite  of  soda.  I^ike 
these  its  action  is  quick,  but  not  quite  immediate.  Dr,  Leech  found  no 
effect  on  the  pulse  at  the  end  of  a  minute  and  a  half,  but  in  three  min- 
utes a  very  marked  effect,  and  in  eight  minutes  the  tension  was  very  low, 
and  it  was  not  fully  restored  at  the  end  of  an  hour  after  the  dose,  fifty 
minims.  lie  found  this  amount  left  a  perceptible  influence  for  one  hun- 
dred and  fifty  minutes,  and  twenty-five  minims  affected  the  pulse  for 
eighty  rtinutes.  These  experiments  coincide  with  our  clinical  experience 
of  the  value  of  this  remedy,  for  as  the  tension  falls  there  is  a  disposition 
to  perspiration,  and  at  the  lowest  point  the  patient  sometimes  breaks 
out  into  profuse  sweats.  We  can  now  understand  how  small  doses  fre- 
quently repeated  act  favorably  in  febrile  conditions. 

There  is  this  difference  between  the  sweet  spirit  of  nitre  and  nitrite 
of  amyl — both  diminish  the  tension  and  quicken  the  pulse,  but  this  latter 
effect  is  not  nearly  so  marked  by  the  spirit  as  by  amyl  nitrite,  and  in 
small  doses  the  acceleration  of  the  pulse  is  often  scarcely  perceptible, 
which  accounts  for  its  not  being  much  observed  or  commented  upon, 
though  very  able  physicians  have  called  it  a  stimulant,  an  antispasmodic, 
and  a  carminative,  while  others  have  said  that  it  acts  on  the  nervous 
sj'stem  chiefly  as  a  diffusive  stimulus,  and  others  again  look  upon  it  as  a 


138  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

stimulant  diaphoretic,  and  say  that  it  is  specially  useful  in  children  in- 
stead of  alcohol,  while  others  again  have  noted  that  it  sometimes  in- 
creases pyrexia.  All  these  observations  are  no  doubt  correct,  and  it  is 
pleasant  to  observe  that  the  clinical  skill  of  our  predecessors  often  en- 
abled them  to  discover  things  which  our  modern  methods  of  research  con- 
firm. 

Various  processes  of  making  the  sweet  spirits  of  nitre  have  been  em- 
ployed and  the  results  have  unquestionably  differed,  to  which  fact  may 
be  attributed  much  of  the  distrust  with  which  the  preparation  has  some- 
times been  regarded.  Moreover,  as  a  popular  remedy  it  has  often  been 
adulterated.  Liquor  ammonise  acetatis,  with  which  it  is  often  prescribed, 
has  also  been  an  uncertain  preparation.  In  each  case  it  is  important  to 
have  a  definite  compound.  These  two  febrifuges  act  admirably  in  com- 
bination, and  form  perhaps  the  most  popular  of  all  those  in  use.  Some- 
times it  is  desirable  to  add  a  little  ammonia  in  order  to  obtain  a  stimu- 
lant diaphoretic.  In  such  case,  however,  a  combination  of  the  spirits  of 
nitre  with  spir.  amnion,  aromat.  is  an  elegant  and  effectual  form.  The 
stimulus  of  the  ammonia  keeps  up  the  cardiac  action  while  the  ethyl  ni- 
trite diminishes  the  arterial  tension.  On  the  other  hand,  when  it  is  de- 
sirable to  moderate  the  heart's  action,  small  doses  of  aconite  may  be  ad- 
vantageously added  to  the  spirits  of  nitre. 

Spirits  of  nitre  is  very  rapidly  eliminated,  both  by  the  kidneys  and 
lungs.  A  single  large  dose  may  therefore  act  chiefly  as  a  stimulant  and 
diuretic.  In  order  to  diminish  arterial  tension  we  should  employ  small 
doses  frequently  repeated.  These  doses  may  have  no  effect  upon  the 
pulse  but  they  will  lower  the  tension  and  so  lead  to  perspiration.  As 
the  action  of  the  drug  resembles  that  of  nitrite  of  amyl  and  nitro-glycer- 
ine,  perhaps  it  might  be  used  instead  of  these  more  powerful  agents.  It 
might  be  well  to  try  whether  a  large  dose  of  sweet  spirits  of  nitre  might 
not  sometimes  prove  an  efficient  substitute  for  amyl  nitrite. 

Jaborandi  and  Pilocarpine. — Though  only  introduced  to  European 
practice  about  ten  years  ago  by  Dr.  Cautinho,  jaborandi  rapidly  estab- 
lished an  important  position,  and  has  already  found  its  way  into  the 
American,  German,  and  French  pharmacopoeias,  and  will  no  doubt  obtain 
a  place  in  the  next  British  revision.  Soon  after  a  dose  of  jaborandi,  or 
of  its  active  principle,  there  is  flushing  of  the  face,  ears,  and  neck,  which 
progresses  downward,  travelling  over  the  whole  body.  In  from  five  to 
ten  minutes  after  the  dose  the  saliva  begins  to  flow  freely  and  soon  after- 
ward perspiration  supervenes,  and  this  lasts  from  two  to  five  hours  and 
is  often  so  profuse  as  to  soak  through  the  clothes.  As  soon  as  the  per- 
spiration is  free  the  flushing  passes  away.  Fereol '  noted  an  interchange 
between   the   amount  of  the  salivation  and    the  sweating,  and   this  may 

'  Fereol:  Note  sur  le  Jaborandi  du  Dr.  Cautinho.     1875. 


DENUTRIENTS.  139 

sometimes  be  observed,  for  with  profuse  salivation  there  may  be  less 
sweating,  and  vice  versa,  but  the  rule  is  by  no  means  absolute.  Occasion- 
ally no  salivation  takes  place,  but  it  is  scarcely  ever  that  there  is  no 
sweating,  though  now  and  then  we  meet  with  individuals  who  seem  to  be 
almost  insusceptible  to  the  action  of  the  medicine.  It  is  curious  that  it 
has  much  less  effect  upon  children  than  upon  adults. 

The  amount  of  sweat  transuded  is  sometimes  enormous.  The  saliva- 
tion, too,  may  be  excessive,  from  a  pint  to  a  pint  and  a  half  being  spit  out, 
besides  what  is  swallowed.  Occasionally  pain  and  swelling  of  the  sali- 
vary glands  follows,  other  secretions  are  also  increased — the  nasal,  the 
bronchial,  the  lachrymal — but  to  a  far  less  degree  than  the  cutaneous 
and  salivary  ;  so  we  have  watering  of  the  eyes,  sneezing-,  irritation  of  the 
nose,  succeeded  by  coryza,  and  a  loose  cough  with  free  expectoration. 
It  is  even  said  that  the  cerumen  of  the  ears  has  been  increased.  Gastric 
uneasiness  is  often  complained  of,  partly  perhaps  due  to  the  saliva  swal- 
lowed, which,  indeed,  is  sometimes  vomited.  When  jaborandi  is  taken  the 
bulk  of  the  remedy  may  also  cause  uneasiness,  but  gastric  disturbance 
is  also  observed  after  pilocarpine.  Gubler  observed  that  diarrhoea  may 
be  produced,  but  this  is  not  frequently  the  case.  He  also  thought  the 
remedy  acted  as  a  diuretic,  and  in  small  doses  it  may  do  so,  but  scarcely 
when  the  sudorific  action  is  marked.  It  has  no  effect  on  the  bile  and  it 
is  doubtful  whether  it  has  on  the  milk. 

The  effect  on  the  temperature  is  not  so  marked  as  might  have  been 
expected,  an  average  fall  of  1°  Fahr.  being  established.  Robin '  thought 
that  a  slight  rise  preceded  the  fall  ;  Riegel  found  no  rise.  More  blood  is 
sent  to  the  skin,  but  the  effect  of  this  may  be  balanced  by  evaporation 
and  radiation.  The  pulse  rises  some  twenty  to  fifty  beats,  but  Langley 
found  an  opposite  effect  produced  in  animals.  The  rise  lasts  from  two 
to  four  hours,  but  the  pulse  is  much  weaker  and  a  good  deal  of  depression 
is  produced  ;  the  blood-pressure  falls  temporarily,  then  perhaps  it  rises  a 
little,  and  finally  a  fall  is  established.  The  heart,  though  the  beat  may 
be  quickened  for  a  time,  is  decidedly  weakened,  so  that  when  this  organ 
is  unequal  to  its  work  jaborandi  is  to  that  extent  contra-indicated.  Metab- 
olism is  increased  and  the  body  weight  falls  ;  the  excess  in  the  secretions 
is  not  merely  water,  but  the  solids  are  increased  ;  thus  abundance  of  salts 
and  ptyalin  are  carried  away  by  the  salivation  and  an  excess  of  urea  by 
the  perspiration.  The  sweat  is  said  to  be  at  first  acid,  afterward  neutral, 
and  at  last  often  alkaline.  Robin  found  it  contained  excess  of  chlorides 
with  some  carbonates  and  phosphates,  but  much  more  important  is  the  in- 
crease of  urea  to  more  than  five  times  its  normal  amount.  Hardy  and 
Ball  estimated  that  an  average  of  seventeen  grains  was  eliminated  by  the 
skin  in  their  experiments,  and  some  even  higher  estimates  have  been  made. 

'  Robiu  :  Etudes  physiologiques  et  therapeittiques  sur  le  Jaborandi.     1875. 


140  THEKAPEUTICS    OF   THE    RESPIRATOEY    PASSAGES. 

Jaborandi  sometimes  affects  the  sight  a  little,  but  without  altering  the 
size  of  the  pupil  ;  its  local  application,  however,  brings  on  contraction 
and  impairment  of  vision,  lasting  from  an  hour  and  a  half  to  occasionally 
twenty-four  hours.  Mr.  Tweedie  concludes  {iMncet,  1875)  that  locally  ap- 
plied it  causes  (1)  contraction  of  the  pupil;  (2)  tension  of  the  accommoda- 
tive apparatus  of  the  eye,  with  approximation  of  the  nearest  and  farthest 
points  of  distinct  vision  ;  (3)  amblyopic  impairment  of  vision  from 
diminished  sensibility  of  the  retina. 

Respiration  is  not  directly  affected,  and  so  we  can  use  this  diaphoretic 
in  bronchial  and  pulmonary  diseases,  but  the  depression  it  produces  on 
the  circulation  and  the  exhaustion  which  sometimes  follows  its  action 
renders  it  unadvisaVjle  to  repeat  it  too  frequently.  The  narcotism  which 
has  been  said  to  follow  it  is  probably  only  that  disposition  to  sleep 
which  may  be  observed  after  profuse  perspiration,  however  induced. 

The  action  of  jaborandi  is  promptly  antagonized  by  belladonna  :  a  hy- 
podermic injection  of  one-one-hundredth  of  a  grain  of  atropia  will  almost 
invariably  arrest  the  sweating  and  salivation,  and  in  case  of  excessive 
action  it  may  be  desirable  to  resort  to  this  antidote. 

The  increase  in  the  salivary  secretion  is  probably  due  to  a  direct 
action  on  the  gland  or  the  ends  of  its  nerves,  as  well  as  to  a  stimulation 
of  the  centre.  Carville  has  shown  ['Tourn.  de  Therap.,  1875)  that  section 
of  the  chorda  tympani  high  up  or  low  down  after  it  has  joined  the  gusta- 
tory nerve  does  not  prevent  the  sialogogue  action  of  the  drug.  Free  sali- 
vation was  produced  even  after  section  of  both  the  gustatory  and  pneu- 
mogastric  nerves  and  destruction  of  the  upper  cervical  ganglion  of  the 
sympathetic.  The  sweating  is  also  due  to  direct  action  on  the  nervous 
periphery,  as  well  as  on  the  centre,  and  perhaps  the  sweat-glands  are 
stimulated  in  the  same  manner  as  the  salivary.  The  sphygmograph 
shows  lowered  vascular  tension.  The  cardiac  depression  is  partly  due  to 
the  action  on  the  vagus  and  partly,  perhaps,  to  direct  action  on  the 
ganglia. 

To  produce  a  single  copious  sweat  in  almost  any  disease  jaborandi 
may  be  employed.  It  may  therefore  serve  as  a  substitute  for  the  Turk- 
ish bath  or  the  lamp  bath.  In  renal  dropsy  it  seems  to  be  indicated,  as 
we  have  seen  that  it  greatly  increases  the  elimination  of  urea.  In  respir- 
atory diseases  a  single  full  dose  will  often  cut  short  a  cold  in  the  same 
way  as  any  other  sudorific.  In  asthma  it  has  sometimes  been  found  to 
give  relief  ;  so  it  has  in  pertussis.  When  the  temperature  is  high  and 
there  is  a  good  deal  of  sthenic  excitement,  it  is  well  to  combine  it  with 
an  arterial  sedative.  In  pleuritic  effusion,  when  there  is  no  cardiac 
weakness,  jaborandi  may  be  employed.  In  diphtheria  somewhat  con- 
tradictor}^  statements  have  been  made.  Guttmann  regards  pilocarpine  as 
a  specific  ;  he  recommended  it  in  every  case,  however  severe,  septic  or 
otherwise.     Soon  after  Dr.  Jacobi  stated  his  experience  at  the  American 


DENUTEIENTS.  141 

Medical  Association  (1881).  In  septic  cases  he  believed  the  treatment 
accelerated  death  by  hastening  the  cardiac  failure,  but  in  many  cases  he 
held  that  the  membrane  was  softened  and  separated  by  the  copious  se- 
cretion produced  by  the  pilocarpine.  He  therefore  attributed  the  re- 
covery, 1,  to  the  macerating  effect  ;  2,  to  the  timely  vsrithdrawal  of  the 
alkaloid.  It  seems  certain  that  the  remedy  greatly  increases  the  secre- 
tion of  the  respiratory  mucous  membrane  and  renders  it  more  fluid,  thus 
tending  to  disintegrate  and  separate  the  false  membranes.  It  is  there- 
fore a  kind  of  expectorant,  and  will  again  be  noticed  under  that  head, 
but  there  is  evidently  danger  of  its  depressing  influence  on  the  heart, 
calling  for  great  circumspection  in  its  use.  If  we  could  find  a  drug 
which  would  antagonize  its  action  on  the  heart  without  interfering  with 
its  influence  on  the  mucous  membrane  we  might  combine  the  two. 
Atropia  unfortunately  dries  up  the  mucous  secretion,  and  we  must  there- 
fore look  to  ammonia,  ether,  etc.,  to  sustain  the  heart.  In  a  robust  pa- 
tient pilocarpine  may  be  employed  without  fear,  provided  it  be  discon- 
tinued in  time,  but  after  its  influence  has  been  obtained  the  use  of  steam 
will  keep  up  the  effect,  and  where  there  is  depression  at  first  this  old 
but  most  powerful  remedy  should  perhaps  be  trusted  altogether.  In 
reference  to  croup  and  diphtheria,  we  must  not  forget  the  peculiar 
insusceptibility  to  jaborandi  and  its  active  principle  manifested  by  chil- 
dren. 

It  has  been  stated  that  small  doses — one-twentieth  grain — of  pilocar- 
pine will  check  colliquative  sweats  in  phthisis.  A  similar  statement  has 
been  made  as  to  other  diaphoretics.  Supposing  this  to  be  the  case,  why 
should  we  not  resort  to  the  far  moi'e  reliable  atropine  or  any  direct  anti- 
hydrotic  ? 


CHAPTEE  XVI. 

ANTIPYEETICS. 

We  have  already  referred  to  the  effects  of  refrigerants  and  sahnes, 
as  well  as  to  acids  and  various  beverages,  in  restraining  febrile  action. 
We  have  also  considered  diaphoretics  and  some  other  methods  of  affect- 
ins:  the  cutaneous  circulation.  We  have  seen  that  the  skin  is  the  great 
regulator  of  the  escape  of  heat  ;  and  we  may  act  upon  it  directly,  as  we 
do,  for  instance,  when  we  reduce  the  external  temperature  or  change  the 
medium  in  which  we  are  living  by  placing  the  body  in  a  bath.  Cold 
baths  and  the  local  application  of  cold  water  or  of  ice  may  be  considered 
external  refrigerants  ;  and  the  introduction  of  cold  or  iced  water  into  the 
body  by  beverages  or  injections  will  affect  to  some  extent  the  general 
temperature,  but  not  so  much  as  might  be  imagined.  Cold,  then,  whether 
by  the  medium  of  water  or  air,  is  the  first  of  the  direct  antipyretics,  and 
appears  to  act  principally  by  withdrawing  heat  from  the  system.  Such 
heat  may  of  course  be  due  either  to  overproduction  or  diminished  dissi- 
pation, causing  accumulation  in  the  body.  It  is  quite  conceivable  that 
fever  may  be  reduced  by  the  mere  abstraction  of  excessive  heat,  or  by  a 
diminution  of  its  production.  For  whatever  disturbs  the  balance  between 
the  production  and  the  loss  of  heat  seriously  affects  us.  When  the  tem- 
perature of  the  atmosphere  rises  there  is  a  greater  dissipation  of  heat  by 
perspiration,  and  by  exhalation  from  the  lungs,  as  well  as  by  a  cooling  of 
the  surface  from  the  blood  flowing  rapidly  through  the  cutaneous  vessels. 
At  the  same  time,  the  call  upon  the  heat-producing  function  being  di- 
minished, it  is  probable  that  less  is  liberated.  So,  again,  during  exercise 
the  skin  flushes,  perspiration  sets  in,  and  quickened  circulation  and  res- 
piration sends  large  quantities  to  be  cooled  at  the  surface  ;  thus,  as  we 
have  said,  the  skin  is  the  chief  regulator,  but  the  lungs  assist  its  action. 

When,  on  the  other  hand,  the  external  temperature  falls,  a  converse 
compensating  process  takes  place.  We  now  have  less  loss  of  heat,  per- 
spiration is  suspended,  and  the  cutaneous  vessels  contract,  the  respiration 
and  circulation  being  retarded.  In  this  case,  in  response  to  the  call  upon 
production,  more  heat  is  liberated,  and  so  the  balance  maintained.  The 
effect  of  a  change  in  the  external  medium  from  air  to  water  will  largely 
depend  on  the  difference  between  the  body  temperature  and  the  bath. 


ANTIPYRETICS.  143 

In  health  we  know  that  the  compensating  powers  o£  the  system  are  such 
that  short  baths  do  not  much  alter  the  temperature  ;  and  so  we  find  that 
our  most  powerful  antipyretic  medicines  have  but  little  effect  on  robust, 
healthy  men.  This  may  be  because  in  health  the  compensating  arrange- 
ments easily  maintain  the  normal  condition,  even  although  it  may  be  ad- 
mitted that  some  of  these  medicines  may  diminish  the  production  of  heat 
by  retarding  metabolism  and  decreasing  excretion.  Quinia  and  the 
salicyl  compounds  diminish  the  excretion  of  urea  and  probably  resorcin, 
chinolin,  kairin,  and  other  such  substances  may  act  in  a  similar  manner  ; 
if  so,  it  would  seem  that  they  should  be  regarded  as  restraining  the  pro- 
duction of  heat.  But  it  is  quite  possible  that  this  is  not  the  true  inter- 
pretation, but  that  in  some  way  they  may  increase  the  dissipation  of 
heat.  Dr.  H.  C.  Wood,  at  the  International  Medical  Congress,  1881,  in 
London,  stated  that  in  experiments  which  he  had  made  jointly  with 
Dr.  Reichert  on  healthy  dogs,  extending  over  two  years,  quinia  nearly 
always  caused  a  slight  increase  in  production  and  always  a  great  increase 
in  dissipation.  The  augmented  production  seemed  to  him  only  an  indi- 
rect result  of  the  excessive  dissipation. 

But  whatever  may  be  the  effect  in  health,  an  increased  heat-produc- 
tion seems  to  be  the  great  cause  of  pyrexia,  and  as  quinia,  the  salicvl 
compounds,  the  phenol  derivatives,  and  other  antipyretics  reduce  the  tem- 
perature, it  is  generally  held  that  they  do  so  by  restraining  the  exces- 
sive production  ;  while  the  cold-bath  treatment,  as  it  manifestly  abstracts 
heat,  is  credited  with  acting  only  in  that  manner,  though  there  are  facts 
which  seem  to  show  that  this  method  also  checks  heat-production.  This 
is  shown  in  the  diminution  of  the  nitrog-en  eliminated,  as  determined  bv 
several  investigations  ;  e.g.,  Barth,  in  186G,  found  that  under  the  action  of 
baths  in  four  cases  of  typhus  and  two  of  typhoid,  the  elimination  of  urea, 
phosphates,  and  chlorides  was  lessened.  This  has  been  corroborated  bv 
Schroeder,  while  in  1879  Bauer  and  Kuenstle  investigated  the  compara- 
tive effects  of  baths,  quinine,  and  salicylate  of  soda,  and  found  that  the 
flow  of  urine  was  increased  by  them  all  ;  but  by  far  the  most  complete 
research  of  this  kind  was  published  by  Dr.  Sassetzky  in  Virchow's 
Archill.,  1883.  He  analyzed  both  the  urine  and  fseces  in  order  to  esti- 
mate the  total  elimination  of  nitrogen.  Further,  in  order  to  determine 
how  much  assimilation  is  interfered  with,  and  to  what  extent  metabolism 
would  account  for  the  nitrogen  eliminated,  the  quantities  of  nitrogenous 
ingesta  were  also  investigated. 

Sassetzky  selected  cases  of  pneumonia,  typhus,  and  relapsing  fever, 
excluding  typhoid  lest  the  intestinal  lesions  should  disturb  the  result. 
In  fifteen  cases  the  nitrogenous  excreta  were  estimated  daily,  both  in  the 
urine  and  fseces.  Furtlier,  the  phosphates  and  chlorides  of  the  urine 
were  determined  and  also  the  solids  and  nitrogenous  substances  ingested. 
Analyses  were  made  in  every  case  during  three  periods  of  from  three  to 


144  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

eight  days  each  ;  viz.,  one  period  in  which  antipyretic  treatment  was 
employed,  one  without  treatment,  and  one  after  pyrexia  had  quite  sub- 
sided. In  nine  of  these  cases  baths  at  72.5°  F.  were  adininistered  four 
times  a  day  for  fifteen  minutes.  In  four  cases  two  ten-grain  doses  of 
quinine  were  given  in  the  evening,  and  in  two  cases  salicylate  of  soda 
was  used. 

The  general  effect  was  diminished  elimination  of  nitrogen.  This  de- 
crease was  noticed  under  all  methods,  but  to  the  greatest  degree  under 
the  baths.  So,  too,  the  quantity  of  urine  was  increased  by  all  methods, 
but  most  of  all  by  the  baths.  Further,  the  assimilation  of  the  solid  and 
nitrogenous  constituents  of  milk  was  improved,  and  this  too  most  of  all 
under  the  baths.  This  was  shown  by  a  very  great  diminution  in  the 
elimination  of  nitrogen  by  the  fseces.  Less  water  was  ingested  under 
the  treatment,  and  the  loss  of  water  by  the  lungs  and  skin  was  decreased, 
except  under  the  salicylate,  under  whicli  there  was  an  increase  of  loss 
through  the  skin. 

Among  the  causes  of  pyrexia,  we  may  assume,  then,  that  increased 
production  of  heat  in  the  tissues  is  the  most  important.  In  fevers  the 
increased  metabolism,  the  excessive  tissue  degeneration,  and  the  rapid  ox- 
idation manifest  themselves  in  the  rapid  emaciation  and  the  great  in- 
crease of  urea  and  other  excretions.  This  conclusion  is  confirmed  by 
other  phenomena  ;  thus  a  chill — which  is  a  sudden  suspension  of,  or  at  least 
interference  with  the  regulating  function  of  the  skin,  causing-  the  vessels 
to  contract  and  so  shivering,  chills,  or  rigors  to  be  felt,  and  bringing  about 
arrest  of  perspiration — hinders  the  escape  of  heat,  whereupon  the  tempera- 
ture rises,  even  though  the  production  be  only  maintained  at  the  usual 
rate  ;  but  if  that  be  quickened,  of  course  the  rise  must  be  more  consider- 
able. It  may  be  thought  that  increased  local  production,  which  we  ob- 
served in  inflammation,  may  also  cause  pyrexia.  No  doubt  this  is  the 
tendency  of  such  a  condition,  but  the  additional  heat  thus  eliminated 
would  probably  only  produce  a  slight  effect  on  the  general  temperature. 
Another  cause  of  pyrexia  is  external  heat,  as  we  see  in  cases  of  sunstroke 
or  thermic  fever.  Again,  the  penetration  into  the  system  of  minute  or- 
ganisms or  other  poisons  capable  of  setting  up  processes  allied  to  fermen- 
tation, tending  to  destroy  the  tissues  and  otherwise  affecting  the  normal 
functions,  rapidly  raise  the  temperature,  as  we  see  in  septic  conditions, 
Avhen  what  may  be  termed  disinfecting  antipyretics  are  naturally  re- 
sorted to.  It  is  supposed  by  some  that  quinine  cures  ague  by  exercising 
a  toxic  influence  over  such  organisms,  and  it  has  been  conjectured  that 
the  salicyl  compounds  exercise  a  similarly  injurious  quality  on  a  hypo- 
thetical microzyme  in  rheumatism.  But  others,  while  freely  admitting 
the  clinical  value  of  these  remedies,  do  not  countenance  that  theory  of 
their  action.  Another  cause  of  high  temperature  would  seem  to  depend 
on  some  interference  with  the  nervous  system.     Thus  in  injury  or  disease 


ANTIPYRETICS.  145 

in  the  upper  portion  of  the  spine  very  high  temperatures  have  been  re- 
corded ;  and  this  fact  may  perhaps  be  attributed  to  a  direct  effect  on  a 
centre  for  heat,  if  such  exist. 

Cold. 

The  ancients  were  not  averse  to  the  use  of  cold,  and  in  fevers  they  ad- 
ministered cold  drinks  freely  ;  but  the  practice  was  disused  and  even- 
tually warm  drinks  only  were  permitted.  Perhaps  this  strange  reversal 
in  modern  times  was  largely  due  to  tlie  ascendancy  of  Boerhaave's  doc- 
trine of  lentor  in  the  blood  as  the  cause  of  fever.  Even  Cullen  hesitated 
to  permit  fever  patients  to  indulge  in  cold  drinks  ;  and  yet,  a  general 
view  of  the  history  of  medicine  would  show  that  in  all  countries,  and  al- 
most in  all  ages,  fever  patients  have  been  treated  successfully  and  pleas- 
antly by  the  external  and  internal  use  of  colds.  Asclepiades,  who  is 
credited  with  the  invention  of  the  shower-bath,  employed  cold  pretty 
freely  ;  but  less  reverence  is  due  to  him  than  to  his  predecessors,  in  con- 
sequence of  the  touch  of  charlatanism  which  characterized  his  practice. 
Suetonius  tells  us  that  Musa  successfully  treated  C^sar  Augustus  by  cold 
baths  ;  and  Horace  relates  in  his  epistles  (book  i.,  15)  that,  under  the 
same  advice,  he  was  to  discontinue  his  warm  baths  and  take  them  cold, 
even  in  frost.  Travellers  in  the  East  tell  us  that  this  method  continued 
long-  after  Europeans  had  learned  to  consider  it  dangerous.  The  ancient 
Britons  and  all  Northern  peoples  had  no  fear  of  cold  water,  and  would 
plunge  into  it  new-born  children,  a  practice  which  continued  general 
down  to  the  fourteenth  century  or  later. 

In  the  fifteenth,  sixteenth,  and  seventeenth  centuries  many  works  on 
the  use  of  cold  water  were  written.  In  17:^1  the  Faculty  of  Medicine  of 
Paris  awarded  a  prize  to  M.  Noquez  for  an  essay  in  which  he  advocated 
water  almost  as  a  universal  specific.  The  next  year  there  appeared  in 
I^ondon  a  curious  work  by  the  Reverend  Dr.  Hancocke,'  which  gave  rise 
to  a  number  of  other  pamphlets  on  the  same  subject,  one  of  which,  issued 
in  172G,  extended  over  nearly  three  hundred  pages,  and  was  entitled, 
"Febrifugum  Magnum,  Morbifugum  Magnum  ;  or,  the  Grand  Febrifuge 
Improved,  being  an  Essay  to  make  it  Probable  that  Common  Water  is 
good  for  many  Distempers,  that  are  not  mentioned  in  Dr.  Hancocke's  'Feb- 
rifugum  Magnum.'  "  Meantime,  Dr.  John  Smith's  "  Curiosities  of  Water"  ^ 
had  appeared,  1723,  and  a  translation  of  Van  der  Hey  den's  "Arthritifu- 
gum  Magnum,"  and  Dr.  Short's  "Rational  Discourse."  In  1729,  Professor 
Cyrillus,  of  Naples,  is  stated  in  the  "  Philosophical  Transactions  "  to  have 

1  Febrifugum  Magnum  ;  or,  Common  Water  the  Best  Cure  for  Fevers  and  probably 
for  the  Plague.     1722. 

-  Smith,  J.  :  Curiosities  of  Common  Water  ;  or,  Advantages  thereof  in  Distempers. 
1723. 

10 


146  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

recommended  water,  and  even  powdered  ice  or  snow,  in  fevers,  both  inter- 
nally and  externally.  In  1730,  Boudon  '  collected  in  two  volumes  thirteen 
essays  on  the  subject  by  various  writers.  In  1734,  De  Hahn  '^  gave  an  ac- 
count of  a  terrible  epidemic  at  Breslau,  in  which  the  mortality  was  not  re- 
duced until  cold  affusions  were  used,  and  in  which  he  himself  suffered  and 
was  restored  by  cold  sponging.  Hoffmann^  (1747),  Smollett^  (1752),  C. 
Lucas' (1756  to  1758)  in  a  very  able  essay,  Percival "  (17G9),  Englehart' 
(1776),  De  Hersfeld*  (1776),  and  many  others  followed.  In  1779,  Dr. 
Wright  presented  to  the  Medical  Society  of  London  an  account  of  a  num- 
ber of  cases,  including  his  own,  in  which  he  had  systematically  employed 
affusions  with  the  greatest  benefit.  On  reading  these.  Dr.  Currie,"  physician 
to  the  Liverpool  Infirmary,  determimed  to  adopt  the  practice,  which  he  did 
with  great  success,  as  testified  in  his  "  Reports,"  the  first  of  which  was  pub- 
lished in  1797  and  the  second  in  1804.  From  this  time  the  modern  practice 
has  been  frequently  dated,  and  Currie  has  been  regarded  as  the  reviver  of 
the  method.  But  Dr.  .Jackson,"  in  1798  and  in  1808,  must  also  be  credited 
with  no  little  influence,  and  although  he  differed  in  some  respects  from 
Currie,  in  many  others  confirmed  his  views.  Indeed,  Dr.  Francis  Adams, 
the  accomplished  translator  of  Hippocrates,  expressed  his  regret  that  the 
profession  did  not  follow  Jackson  rather  than  Currie.  Dr.  J.  E  Stock  " 
in  1805  produced  his  "  Medical  Collections  on  Cold."  Giannini  "  and  Mal- 
lonay  '^  (1805)  recommended  cold  baths  in  all  forms  of  fever.  Frohlich  '* 
(1820)  regulated  his  practice  by  the  use  of  the  thermometer.  In  1819 
Dr.  Bateman,  in  his  treatise  on  cutaneous  diseases,  pronounced  cold  water 

'  Boudon  :  Les  vertiis  medicinales  de  I'Eau  commune  ou  Recueil  des  Meilleures 
Pieces,  etc.     2  vols.     1730. 

^  De  Hahn :  Unterricht  von  der  Kraft  imd  Wirkung,  des  f rischen  Wassers  in  die 
Liebe  der  Mensclien.    1734. 

^  Hoffmann,  J.  A.  :   De  usu  et  virtute  aquae  simplicis.    1747. 

*  Smollett :  Essay  on  the  External  Use  of  Water.    1753. 

'Lucas,  C.  :  Essaj'  on  Waters.  In  three  parts,  treating  of  1,  Simple  Waters  ;  2,  Cold 
Medicated  Waters  ;  8,  Natural  Baths.     3  vols.     1756-1758. 

'  Percival :   Experiments  and  Observations  on  Water.    1769. 

''Englehart.  F.  J.  :   Dissertatio  sistens  aquffi  frigidae  interno.     1774. 

*De  Hersfeld,  St.  :   De  Aquie  communis  differentiis  usu  et  Viribus.    1776. 

9  Currie,  J.  :  Medical  Reports  on  the  Effects  of  Water,  Cold  and  Warm,  as  a 
Remedy  in  Fever  and  Febrile  Diseases.     1797.     Second  Series.  1804. 

lojack.son.  Outline  of  the  History  and  Cure  of  Fever.  1798.  Exposition  of  the 
Practice  of  Affusion  ;  Cold  Water  on  the  Surface  of  the  Body  as  a  Remedy  of  Fever  ; 
to  which  are  added  On  the  Effects  of  Cold  Drinks,  etc     1808. 

"  Stock:  Medical  Collections  on  the  Effects  of  Cold  as  a  Remedy  in  Certain  Dis- 
eases.    1 805. 

'*  Giannini :  Delia  natura  delle  febbri.      1805. 

'^Mallonay  :  De  usu  aquae  frigidfe  in  febribus.     1805. 

'^  Frohlich,  A.  :  Griindliche  Darstellung  des  Heilverfahrens  in  entzundlichen  Fie- 
bern  uberhaupt  and  insbesondere  in  Scharlach,  etc. 


ANTIPYEETICS.  147 

"  the  most  effectual  febrifuge,"  and  commented  on  its  "  certainty,  safety, 
and  promptitude  "  in  scarlet  fever.  In  1826,  Dr.  Macartney  ^  in  his  lec- 
tures pronounced  water  to  be  "  worth  all  other  remedies  put  together," 
and  his  opinions  exercised  no  little  influence  over  his  contemporaries. 

Then  came  a  period  in  which  the  scientific  use  of  cold  was  less  in 
favor,  this  potent  remedy  having  been  taken  up  by  ignorant  empyrics, 
and  hydrotherapeutics  thereby  degraded  into  hydropathy,  Priessnitz 
opened  his  establishment  at  Griifenberg  in  1828,  and  many  enthusiasts 
and  speculators  embarked  in  the  business  ;  no  wonder,  therefore,  that  a 
remedy  thus  exploited,  and  the  reckless  and  ignorant  use  of  which  often 
led  to  catastrophes,  should  have  been  looked  upon  with  some  suspicion. 
Nevertheless,  from  time  to  time  articles  and  treatises  of  scientific  value 
were  produced,  such  as  those  of  Dr.  J.  Arnott,  who  from  about  1849,  when 
he  advocated  congelation  in  inflammation,  continued  to  show  the  use  of 
cold  under  various  circumstances,  and  still  later,  Esmarch,  whose  treatise  on 
"Cold  in  Surgery"  has  been  translated  for  the  New  Sydenham  Society. 

We  come  now  to  the  last  revival  of  the  use  of  cold  as  an  antipyretic, 
which  dates  from  the  appearance  of  Ernest  Brand's^  work  (1861)  on 
typhoid  ;  which,  although  perhaps  too  enthusiastic,  restored,  so  to  say, 
the  proper  and  systematic  use  of  cold  baths,  extended  the  area  of  their 
application,  and  excited  the  attention  of  the  profession.  Jilrgensen,  of 
Kiel,  followed  his  method,  and  in  due  time  published  a  work  on  typhoid 
(1866)  embodying  three  years'  experience.  His  results  were  such  that 
the  Kiel  system  spread  through  most  of  the  German  hospitals,  and  as 
gradually  extended  over  other  countries.  Llebermeister  and  Hagenbach  ^ 
followed  in  a  joint  work  in  18G8,  which  added  greatly  to  our  reliable  evi- 
dence on  the  subject,  and  the  following  year  Kiichenmeister  published  a 
very  handy  summary  of  trustworthy  results,  and  Ziemssen  and  Immer- 
mann,''  published  an  important  work  on  typhoid,  of  which  a  much  en- 
larged and  more  complete  edition  appeared  in  1874.  The  Franco-Ger- 
man War  contributed  largely  to  the  extension  of  the  method  in  Europe  ; 
but  Germany  is  still  the  home  of  the  treatment,  and  the  works  named  the 
most  important  contributions  to  its  literature.  M.  Peter  (  Union  Medi- 
cale,    1777),    Glenard,^    Behier,"    Raynaud,''    Pecholier,*    Dumontpallier, 

'  Macartney  :  Lectures  in  Trinity  College,  Dublin.      1826. 

*  Brand,  E.  :  Die  Hydrotherapie  des  Typhus.     1861. 

^  Liebermeister  and  Hagenbach :  Aus  der  medizinische  Klinik  zu  Basel.  Beobach.  n. 
Versuche  iiber  die  Anwendung  des  Kalten  Wassers  bei  fieberhaften  Krankheiten.   1868. 

■*  Ziemssen  and  Immermann :  Die  Kaltwassenbehaudlung,  des  Typhus  abdom- 
inalis.     1869.  , 

'  Glenard  :   Traitement  de  la  Fievre  typhoide  par  les  bains  froids.     1875. 

*  Behier  :   Du  traitement  de  la  Fievre  typhoide  par  les  bains  froids.     1874. 

'  Raynaud  :  Application  de  la  methode  des  bains  froids  au  traitement  du  Rhuma- 
tisme  Cerebral.     1874. 

^  Pecholier  :  Sur  les  indications  du  traitement  de  la  Fievre  typhoide.     1874. 


148  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

Homolle  {Revue  Generale,  1878),  Fereol  (  Union  3Ied.),  and  others  have 
adopted  the  method  in  France  ;  Barduzzi '  and  others  in  Italy.  In 
Eno-laiid  we  have  adopted  the  method,  but  with  considerable  caution,  and 
certainly  without  enthusiasm.  Dr.  Wilson  Fox,  in  1871,  proved  the 
value  of  the  method  by  rescuing'  a  patient  from  hyperpyrexia  in  the 
course  of  acute  rheumatism,  and  a  number  of  other  patients  have  been 
saved  by  the  same  plan.  Sir  Spencer  Wells  reduced  the  fever  previous 
to  the  removal  of  a  suppurating  ovarian  cyst,  after  the  temperature  was 
brought  down  to  a  hundred,  having  previously  varied  between  102°  and 
104°  F.  [3fedical  Times,  1872).  Baths  have  since  been  employed  more 
or  less  assiduously  in  a  number  of  the  London  hospitals,  but  the  treat- 
ment is  by  no  means  universally  adopted. 

Baths  gradually  cooled  down  from  95°  to  72°  F.,  or  lower,  are  some- 
times employed,  as  recommended  by  Von  Ziemssen,  a  method  often  called 
after  his  name,  though  he  has  since  almost  abandoned  it  ;  as  this  plan 
takes  longer  to  produce  the  same  effect.  Liebernieister  recommends  a 
full  length  bath  of  68°  F.,  or  lower,  in  typhoid  for  adults,  for  a  period  of 
ten  minutes — if  kept  in  longer  it  is  unpleasant  and  may  do  mischief.  If 
the  patient  should  be  feeble  and  continue  cold,  or  be  collapsed,  the  time 
is  reduced  to  seven  or  five  minutes,  and  he  thinks  this  better  than  using 
a  long  tepid  bath.  Very  feeble  patients  may  begin  at  75°  F,,  but  the 
effect  is  much  less,  or  Ziemssen's  plan  may  be  tried.  In  common  with 
other  German  observers,  he  insists  that  the  baths  to  be  effectual  must  be 
given  often.  The  temperature  should  be  taken  every  two  hours,  and 
whenever  it  rises  to  102.2°  F.  in  the  axilla  the  bath  is  to  be  renewed. 
In  children,  inasmuch  as  the  body  is  larger  compared  to  the  weight,  we 
may  wait  till  the  temperature  reaches  103°  F,  in  the  axilla,  or  104°  F.  in 
the  rectum,  as  we  may  also  in  persons  who  are  known  to  resist  heat  well  ; 
but  in  those  in  whom  the  resisting  power  is  less  it  is  well  to  commence 
earlier,  with  perhaps  a  shorter  bath,  or  else  a  little  higher  temperature. 
He  regards  it  as  a  delusion  to  suppose  that  a  few  baths  will  do  any  good. 
When  the  disease  is  severe,  the  interior  of  the  body  is  only  slightly 
cooled,  and  that  for  a  short  time,  by  a  single  bath.  It  is  therefore  nec- 
essary to  repeat  the  baths,  sometimes  every  two  hours,  and  this  is  to  be 
done  both  night  and  day,  so  that  twelve  may  be  required  in  the  twenty- 
four  hours,  and  some  of  his  typhoid  patients  have  taken  more  than  two 
hundred  during  the  illness.  Usually  from  four  to  eight  per  diem  have 
sufficed,  and  from  forty  to  sixty  in  the  course  of  the  illness,  especially  if 
antipyretic  medicines  were  also  given. 

There  is  no  doubt  that  the  baths  are  4isagreeable  to  the  majority  of 
patients,  and  it  often  requires  persuasion,  or  even  the  exercise  of  author- 
ity on  the  part  of  the  physician  to  secure  his  orders  being  properly  car- 

'  Barduzzi :   Dell'  Idrotlierapia  uelle  Febbri  Tifoidee.     1874. 


ANTIPYRETICS.  149 

ried  out — the  more,  perhaps,  as  the  method  is  troublesome  and  very 
exacting  for  the  attendants.  Later  on,  having  experienced  the  benefits, 
the  patients  desire  to  continue  the  baths  after  the  necessity  for  them  has 
passed  by.  They  feel  hot,  and  desire  the  refreshing  cold  they  have  pre- 
viously enjoyed.  With  a  rectal  temperature  of  101.5°  F.  they  may  be  in- 
dulged, but  when  it  falls  below  that  cold  sponging  will  be  found  suffi- 
cient, or  cold  packs,  or  other  local  modes  of  abstracting  heat. 

The  most  important  contra-indication  admitted  by  Liebermeister  is 
hemorrliage  from  the  bowels.  He  does  not  suspend  the  baths  on  account 
of  pneumonia  or  hypostatic  congestion,  which  often  disappear  under  the 
treatment.  Great  weakness  of  the  heart's  action  also  contra-indicates 
the  baths,  for  when  the  circulation  is  so  reduced  that  the  surface  is  cold, 
even  thougli  the  interior  may  be  hot,  there  is  no  likelihood  that  further 
cooling  of  the  surface  will  much  reduce  the  interiial  heat,  while  it  might 
cause  still  more  obstruction  of  the  peripheral  circulation.  In  slighter 
cardiac  weakness  we  may  resort  to  the  gradually  cooled  bath.  Wunder- 
lich  does  not  admit  that  hemorrhage  is  any  contra-indication  (Schmidt's 
t/a/trb.,  clvi.,  p.  101).  He  treated  sixteen  cases  in  which  there  was  in- 
testinal hemorrhage  with  only  two  deaths,  and  neither  of  these  were  from 
the  hemorrhage,  but  one  was  due  to  perforation  and  one  to  pneumonia. 
Bauer  and  otiiers  follow  Liebermeister  in  discontinuing  the  baths  when 
hemorrhage  sets  in,  and  this  seems  reasonable,  inasmuch  as  they  would 
be  likely  to  increase  the  hemorrhage,  and  the  necessary  moving  of  the 
body  might  be  dangerous.      Menstruation  is  not  a  contra-indication. 

In  2^neumonia  cold  baths  have  been  freely  employed,  particularly  by 
.Jiirgensen,  who  is  perhaps  the  most  enthusiastic  advocate  of  tlieir  use 
wherever  there  is  fever.  Not  only  in  croupous  pneumonia — which  he  re- 
gards as  an  infective  fever,  looking  upon  the  inflammation  of  the  lung 
as  merely  the  chief  symptom,  and  the  pyrexia  the  essential  thing  to  treat — 
but  even  in  catarrhal  pneumonia  he  resorts  to  this  method.  He  employs 
usually  baths  from  77°  to  86°  F.  for  twenty  or  twenty-five  minutes  and 
then  cold  affusions.  The  younger  the  patient  the  greater  the  need,  in 
his  view,  of  active  interference,  and  accordingly  in  young  children  he  is 
more  careful  than  in  older  patients  to  treat  every  fever  attended  with 
catarrh  by  the  general  abstraction  of  heat.  Cold  packs,  he  declares  are 
more  severe,  if  thoroughly  carried  out,  and  give  rise  to  much  greater 
discomfort.  As  lie  considers  the  pyrexia  of  croupous  pneumonia  to  be  the 
first  point  to  attack,  he  puts  aside  the  fear  of  catching  cold  as  mere  non- 
sense, and  even  says  that  if  he  had  no  water  in  a  given  case  he  would 
not  hesitate  to  expose  a  patient  to  cold  air  until  the  necessary  cooling 
had  been  obtained.  In  opposition  to  all  prejudices,  he  insists  that  the 
proper  treatment  consists  in  the  abstraction  of  heat,  and  in  this  he  is 
largely  supported  by  Liel^ermeister  and  others.  The  fear  that  an  over- 
worked heart  may  be  paralyzed  in  consequence  of  the  increased  demand 


150  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

made  on  both  the  heart  and  respiratory  muscles  during  the  bath  he  ad- 
mits to  be  reasonable,  but  thinks  it  may  be  prevented,  that  is  to  say,  he 
does  not  deny  that  fatal  collapse  may  occur,  but  the  administration  of  a 
preliminary  stimulus  will  prevent  this.  He  gives  two  tablespoonfuls  o£ 
claret  immediately  before  and  immediately  after  each  bath,  and  if  the 
heart  be  not  working  satisfactorily  he  employs  port,  madeira,  or  cham- 
pagne. When  the  bath  is  quite  cold  he  gives  one  to  three  spoonfuls  of 
the  stronger  wines  five  minutes  before,  repeats  the  dose  while  in  the 
bath,  and  again  immediately  after.  Children  may  require  relatively 
larger  doses ;  in  all  cases  the  quantity  is  to  be  regulated  by  the  pulse,  and 
he  is  well  assured  that  those  who  would  avoid  accidents  must  not  spare 
stimulants.  The  abstraction  of  heat  is  intended  to  guard  against  car- 
diac exhaustion,  and  the  danger  of  this  arises  from  the  fever,  so  that  in 
strong  persons  in  a  moderately  severe  attack  the  treatment  adopted  by 
the  German  school  is  almost  the  same  as  for  typhoid.  Jiirgensen,  for 
example,  with  a  rectal  temperature  of  104°  gives  baths  of  from  seven  to 
twenty-five  minutes,  though  he  employs  at  the  same  time  quinine  ;  but 
in  feeble  patients,  in  the  aged,  and  in  the  corpulent  the  temperature  rarely 
reaches  that  point,  but  most  commonly  varies  from  101°  to  103°  F. 
These  are  the  cases  which  require  special  care,  and  in  them  it  is  best  to 
take  advantage  of  the  usual  rise  and  fall  during  the  twenty-four  hours, 
giving  a  tepid  bath  from  77°  to  78°  F.  from  twenty  to  thirty  minutes  at 
a  time  early  in  the  morning,  say  from  four  to  seven  o'clock,  when  the 
temperature  is  at  the  lowest,  and  at  the  same  time  a  dose  of  quinine. 
Young  children  may  be  treated  with  the  wet  sheet,  which  in  this  country 
is  usually  considered  milder,  but  Jiirgensen  believes  that  it  is  more 
troublesome  and  gives  rise  to  more  discomfort.  The  application  of  cold 
cloths  to  the  chest  only  he  considers  to  be  quite  useless  in  children  over 
one  year  of  age,  as  sufficient  heat  is  not  abstracted  by  this  method, 
though  other  observers  place  more  confidence  in  the  local  application  of 
cold.  In  some  cases  of  pneumonia  the  temperature  rises  so  high  that 
the  most  energetic  and  repeated  efforts  to  lower  it  are  called  for.  In 
these  he  has  often  given  baths  at  Gl°  or  60°  F.  for  ten  minutes  at  a  time, 
and  then,  the  temperature  returning  quickly,  he  has  given  the  bath  at 
43°,  43°,  and  even  41°  F.  His  own  child  he  treated  when  nineteen  months 
old  in  this  manner  for  several  days  without  the  slightest  indication  of 
collapse,  and  has  repeatedly  resorted  to  the  plan  during  the  last  few  years. 
But  we  must  remember  that  he  regards  the  simultaneous  administration 
of  wine  as  an  essential  part  of  the  treatment — giving  adults  from  half  a 
bottle  to  a  bottle  a  day,  including  of  course  the  doses  given  before  and 
after  each  bath.  This  is  the  ordinary  red  wine  of  Germany,  and  we  may 
use  claret,  but  in  severe  cases,  as  already  stated,  he  does  not  hesitate  to 
use  stronger  wines,  and  if  the  heart  show  signs  of  failure  even  hot 
grog.     Further,  the  simultaneous   use  of  quinine  is  most   important,  as 


ANTIPYKETICS.  151 

this  remedy  above  all  others  reduces  the  temperature  without  injuring 
the  heart. 

This  brings  us  to  a  consideration  of  the  danger  of  cardiac  failure, 
which  in  some  cases  of  pneumonia  is  most  urgent,  and  demands  active 
treatment.  In  consequence  of  the  congestion  in  the  pulmonary  circu- 
lation tlie  right  ventricle  suffers  while  the  left  is  comparatively  empty. 
In  severe  cases  blood  accumulates  in  the  veins  of  the  systemic  circula- 
tion, in  consequence  of  the  obstructed  right  ventricle.  Pulmonary 
cedema  may  occur,  and  generally  does  in  fatal  cases.  Tiie  respiratory 
and  cardiac  muscles  at  the  same  time  receive  only  an  insufficient  supply 
of  blood.  It  is  obviously  desirable  to  prevent  such  a  train  of  symptoms, 
and  when  this  is  impossible,  the  earlier  the  treatment  is  directed  toward 
them  the  greater  will  be  the  probability  of  relieving  them.  It  has  been 
generally  held  that  the  indication  here  is  complete  for  blood-letting, 
which  at  once  should  relieve  the  heart,  and  clinical  evidence  shows  that 
such  relief  is  prompt  and  almost  certain.  Nevertheless,  great  objections 
have  been  raised  to  this  remedy,  the  chief  of  which  is  that  the  symptoms 
are  likely  to  return,  and  a  repetition  of  blood-letting  is  undesirable. 
Efforts  have  therefore  been  made  to  stimulate  the  heart  to  increased 
work  until  tlie  obstacle  in  the  pulmonary  circulation  is  overcome.  For 
this  purpose  stimulants  have  been  largely  used,  and  even  Jurgensen 
employs  them  largely,  though  he  advocates  the  bath  treatment  so  ear- 
nestly ;  indeed,  he  says  that  the  most  dangerous  enemy  to  the  heart  is 
the  high  temperature,  and  this  may  be  safely  and  quickly  lowered  by 
the  bathino-.  But  then  we  must  add  stimulants,  which  he  believes  not 
only  spur  the  heart  to  perform  increased  labor,  but  directly  enable  it  to 
do  so.  As  each  vigorous  beat  forces  more  blood  from  the  overfilled 
right  ventricle  into  the  left,  it  benefits  the  heart  by  supplying  it  with 
more  oxygen,  while  it  removes  the  accumulated  debris  of  oxidation. 
The  quantity  of  blood  is  left  unchanged,  increase  of  exertion  has  re- 
lieved the  temporary  embarrassment  ;  but  he  says  that  a  bold  use  of 
stimulants  will  maintain  life  tliree  or  four  days  or  more  after  the  heart 
has  shown  signs  of  exhaustion.  Strong  wine  he  gives  with  tlie  first  in- 
dication of  cardiac  failure,  and  if  the  symptoms  continue  alternates  the 
wine  every  hour  or  half  hour  with  full  doses  of  camphor,  and  if  sudden 
or  severe  collapse  occur,  musk,  one  or  two  grains  at  a  dose,  with  a  table- 
spoonful  of  champagne  at  intervals  of  ten  minutes  to  half  an  hour  ; 
when  the  patient  cannot  swallow,  hypodermic  injections  of  camphorated 
oil,  of  which  he  speaks  highly.  He  also  gives  hot  grog  to  obtain  a  more 
rapid  effect  than  from  champagne,  or  brandy  or  other  spirit  diluted  with 
strong  tea  or  coffee. 

This,  it  will  be  seen,  is  a  stimulating  treatment,  of  which  much  has 
been  said.  If  stimulation  can  tide  over  the  immediate  danger  it  seems 
rational  to  employ  it,  but  it  should  not  be  forgotten  that  stimulation  is 


152  THERAPEUTICS    OF    THE    EESPIRATORY    PASSAGES. 

not  nutrition,  and  does  not  deserve  the  name  of  "  support"  which  is  too 
often  applied  to  it.  There  is  nothing  unreasonable  in  using  the  spur  or 
the  whip,  but  neither  can  supply  the  place  of  coru  to  tlie  struggling 
horse,  though  Jiirgensen,  like  other  advocates  of  stimulants,  would 
persuade  us  that  they  supply  tlie  place  of  both.  Nor  is  it  so  unphilo- 
sophical  to  resort  to  stimulants,  after  a  previous  blood-letting  has  re- 
lieved the  over-burdened  heart  ;  and  so,  again,  it  is  not  unreasonable  so 
to  use  stimulants  as  to  enable  the  heart  to  bear  the  bath  treatment, 
which  doubtless  increases  its  labor  for  the  time  being,  but  then  dimin- 
ishes it.  If  the  heart  can  only  be  tided  over  the  temporary  extra  work 
the  baths  may  be  employed,  and  this  may  generally  be  managed  unless 
the  collapse  be  extreme.  Massive  closes  of  quinine  should  be  adminis- 
tered at  the  same  time.  This  is  by  far  the  most  potent  antipyretic  ;  it 
does  not  injure  the  heart,  and  is  not  open  to  the  objections  which  may 
be  made  to  stimulants,  though  we  readily  admit  that  the  free  use  of 
wine  or  spirits  in  such  urgent  circumstances  bears  no  more  relation  to 
their  use  as  beverages  than  does  the  exhibition  of  a  dose  of  morphia  to 
the  pernicious  habit  of  opium  eating.  Since,  however,  alcohol  has  been 
admitted  to  be  antipyretic  in  considerable  doses,  there  has  been  a  ten- 
dency to  employ  this  fact  in  support  of  the  system  of  stimulation.  (See 
previous  chapter  on  Alcohol.) 

In  scarlet  fever  cold  has  always  been  a  favorite  remedy.  Currie  em- 
ployed it,  as  did  Jackson,  Laycock,  Trousseau,  and  various  others  before 
and  since,  and  they  all  report  well  of  it,  the  majority  employing  affusions. 
More  recently  G.  Meyer  '  puts  a  child  into  a  bath  of  93°  to  73°  F.,  ac- 
cording to  the  intensity  of  the  fever,  for  about  ten  minutes  whenever  the 
temperature  rises  to  102°  F.  This  is  sufficient  to  insure  a  reduction 
lasting  for  several  hours.  Others  prefer  cold  packs  or  cold  sponging,  or 
the  application  of  cold  compresses  to  the  trunk  and  ice  to  the  throat,  but 
these  measures  do  not  reduce  the  temperature  so  decidedly,  and  require 
to  be  continually  renewed.  When,  therefore,  the  temperature  runs  high 
the  bath  is  a  much  more  potent  remed\\ 

In  diphtheria  favorable  results  have  been  reported  from  the  use  of 
cold  baths,  and  as  much  may  perhaps  be  said  for  a  great  many  other 
remedies.  This  disease  is  not,  as  a  rule,  characterized  by  the  very  high 
temperatures  which  urgently  call  for  the  treatment,  and  in  this  country 
the  method  has  only  been  resorted  to  now  and  then  to  meet  the  special 
indication  of  an  unusually  high  temperature.  But  the  local  use  of  cold 
to  the  throat  by  means  of  ice-bags  or  ice-poultices  has  been  much  more 
largely  employed,  though  with  less  success  than  has  been  looked  for. 

With  respect  to  the  success  of  the  antipyretic  system,  statistics  cer- 
tainly show  a  reduced  mortality  to  that  which  prevailed  prior  to  its  adop- 

'  Jahrb.  f .  Kiuderk. ,  vii. 


ANTIPYKETICS.  153 

tion  in  the  most  important  German  hospitals.  Roughly  it  is  claimed  that 
in  tvphoid  the  mortality  has  been  reduced  from  sixteen  to  eight  per  cent, 
by  systematic  antipyretic  treatment,  of  course  including  besides  cold  the 
use  of  quinine  and  other  agents.  If  we  exclude  mild  cases,  there  is  a 
mortality  of  ten  or  eleven  per  cent.,  as  against  twenty-five  to  thirty  under 
the  expectant  plan.  And  a  still  further  sifting  of  the  statistics  would,  it 
has  been  claimed,  show  a  still  more  favorable  result.  Brandt  has,  indeed, 
claimed  that  if  we  exclude  cases  already  moribund  when  admitted,  none 
would  die  ;  and  Glenard  says  that  there  would  scarcely  be  a  death  in  five 
or  six  thousand  cases  thus  treated  from  the  commencement.  These  en- 
thusiastic statements  have  scarcely  produced  the  effect  that  might  have 
been  expected  had  they  been  generally  accepted  ;  but  all  observers 
agree  that  the  mortality  has  been  greatly  reduced  by  antipyretic  treat- 
ment, and  that  the  patients  are  left  stronger  tiian  when  they  are  aban- 
doned to  mere  expectancy.  Goldtdammer'  contrasted  2,008  cases  treated 
in  Berlin  between  18G8  and  1876  with  2,238  cases  treated  between  1848 
and  1867.  The  deaths  were  13.2  per  cent,  in  the  later  period,  instead  of 
18.1  in  the  earlier,  showing  a  difference  of  five  per  cent,  in  the  mortality 
in  favor  of  the  period  after  the  adoption  of  the  antipyretic  system. 
There  was  also  a  difference  in  the  time  spent  in  hospital,  amounting  on 
the  average  to  0.3  days  in  favor  of  cold.  He  admits,  however,  as  others 
have  been  obliged  to  do,  an  increase  in  the  proportion  of  relapses,  and 
supposes  that  this  may  be  due  to  the  bathing  hindering  the  natural  de- 
struction of  the  poison  in  the  body.  To  effect  this,  Immermann,  who 
also  adopts  this  view,  prescribes  a  daily  dose  of  salicylate  of  soda,  and 
since  he  adopted  this  remedy  he  has  found  a  great  reduction  in  the 
number  of  relapses. 

As  to  respiratory  diseases,  Jiirgensen's  statistics  are  very  remarkable. 
He  claims  a  reduction  in  the  mortality  of  at  least  one-half  in  four  hundred 
cases  treated  in  the  same  hospital,  compared  with  the  same  number  prior 
to  the  adoption  of  the  method.  He  admits,  indeed,  as  nobody  can  deny, 
that  patients  recover  from  pneumonia  under  all  sorts  of  treatment,  and 
that  mild  cases  require  little  more  than  regulation  of  the  diet,  but  even 
in  them  he  prefers  active  interference  to  mere  expectancy,  and  thinks 
that  for  the  future  it  must  be  regarded  as  settled  that  all  prostrating 
measures  are  injurious,  and  that  all  antipyretics  which  depress  the  heart, 
if  given  in  doses  sufficient  to  reduce  temperature,  are  to  be  avoided. 
Most  prudent  physicians  will  be  inclined  to  adopt  the  last  conclusion, 
but  it  may  be  observed  that  treatment  which  reduces  the  pulse,  and 
which  would,  if  pushed  too  far,  tend  to  paralyze  the  heart,  may,  when 
cautiously  employed,  produce  decided  benefit,  and  therefore  be  far  better 
than  impotent  expectancy,  while  it  is  not  attended  by  the  dangers  which 

'Deatscli.  Arch.  f.  klin.  Med.,  xx.,  1877. 


154  THERAPEUTICS    OF    THE    KESPIRATORY   PASSAGES. 

are  admittedly  present  when  very  active  measures  are  employed.  Thus 
we  have  treated  pneumonia  successfully  by  moderate  doses  of  quinine 
and  other  antipyretics,  and  especially  by  aconite.  But,  as  already  re- 
marked, similar  statements  may  be  made  in  support  of  other  methods, 
and  we  have  seen  rapid  and  complete  recovery  follow  venesection  and 
counter-irritation,  as  we  have  also  the  directly  opposite  method  of 
stimulation.  Such  facts  to  some  extent  account  for  pneumonia  having 
been  a  kind  of  battle-field  for  contending  theorists,  and  perhaps  we  may 
learn  from  them  that  while  healthy  human  beings  may  be  expected  to 
shake  off  a  serious  disease,  all  treatment  to  be  effective  should  be  directed 
rather  to  the  condition  of  the  individual  patient  than  to  the  particular 
disease  by  which  he  is  attacked. 

Cold  Affusions. — Though  these  have  been  mentioned  incidentally,  we 
have  thus  far  treated  chiefly  of  baths.  Affusions,  however,  have  been 
employed  from  early  times,  and  are  often  very  useful  when  circumstances 
forbid  a  resort  to  the  more  powerful  measure.  Affusions  are  less  disa- 
greeable, and  often  they  are  pronounced  pleasant,  but  they  do  not  lower 
the  temperature  much,  or  for  a  long  period,  and  they  are  often  used  as  a 
sudden  stimulus  to  the  respiration,  and  to  other  functions  rather  than  as 
antip3'retics.  To  produce  a  decided  effect  a  considerable  quantity  of 
water  should  be  employed,  from  one  to  three  gallons,  and  that  very  cold  ; 
it  should  be  poured  from  a  moderate  height,  in  a  full  stream,  over  the 
nape  in  such  a  way  as  to  run  down  the  back  and  chest — this  plan  may  be 
adopted  in  the  late  stages  of  pneumonia. 

Cold  packs  are  well  borne,  even  by  very  weak  patients,  especially 
■when  they  do  not  include  the  feet  or  legs,  and  four  consecutive  packs,  of 
ten  to  fifteen  minutes'  duration,  may  be  regarded  as  about  equal  to  a  bath 
of  ten  minutes.  But  when  using  them  in  this  way,  a  shorter  time  is 
perhaps  desirable,  otherwise  the  reaction  which  ensues  leads  to  per- 
spiration, and  we  have  a  different  remedy  in  use.  Some  quite  young 
children  take  the  packs  with  pleasure,  but  others  resist  them,  fearing 
them  as  much  as  the  bath,  which  is  certainly  the  least  trouble  in  children, 
and  very  effectual. 

Cold  Sponging. — Cold  sponging  will  produce  an  antipyretic  effect, 
provided  it  be  repeated  pretty  constantly,  but  even  then  cannot  be  re- 
garded as  a  substitute  for  bathing.  A  single  sponging,  even  with  very 
cold  water,  although  it  may  be  agreeable  to  the  patient,  can  scarcely  be 
expected  to  produce  much  effect  on  the  thermometer.  Surgeon-Major 
Welch  thinks  (Brit.  3Ied.  J.,  1884)  the  best  course  is  to  frequently  sponge 
with  "  chilly"  water,  not  wiping  it  off,  and  merely  cover  the  body  with 
a  light  sheet,  or  not  even  that  ;  in  severe  cases  he  makes  the  applica- 
tion continuous  by  a  wet  sheet  packed  close  to  the  body,  and  suggests 
the  use  of  a  "  punkah  "  to  assist.  The  use  of  wet  towels,  continually 
renewed  as  fast  as  they  become  warm,  is  easier,  perhaps,  and  more  effect- 


ANTIPYRETICS.  155 

ual  ;  this  plan  has  been  largely  employed  and  is  especially  applicable 
when  it  is  desired  to  limit  the  cold  to  the  trunk. 

Dumontpallier  uses  a  refrigerating  envelope,  and  Leube  has  shown 
that  a  considerable  reduction  of  temperature  may  be  obtained  by  placing 
the  patient  on  large  pillows  containing  a  freezing  mixture  of  ice  and 
salt.  Dr.  Mundie  {Brit.  Med.  J.,  1884)  placed  a  patient  whose  tempera- 
ture was  106°  F.  on  a  Hooper's  bed  filled  with  cold  water,  with  only  a 
single  blanket  between  the  bed  and  patient.  In  six  hours  the  tempera- 
ture fell  two  degrees,  and  next  day  it  was  103°  F.  Cold  may  also  be  ap- 
plied much  more  locally  by  means  of  compresses,  ice-bags,  ice-poultices, 
etc.  If  long  continued  they  seem  to  lower  the  temperature  of  the  local- 
ity to  a  not  inconsiderable  depth,  and  are  therefore  believed  to  protect 
the  subjacent  organs,  and  to  influence  their  circulation.  For  this  pur- 
pose they  are  often  employed  on  the  head  or  chest.  Leiter's  coils  afford 
a  very  convenient  method  of  applying  cold  locally.  These  plans  scarcely 
affect  the  general  temperature.  Riegel  {Deutsch.  Arch.  f.  klin.Med.,  1872) 
employed  a  couple  of  ice-bladders,  one  on  the  thorax,  the  other  on  the 
abdomen  ;  but  other  German  authorities  failed  to  obtain  much  reduction 
of  temperature  in  severe  pyrexia,  even  by  employing  three  bladders. 

Cold  by  Sprays. — Prof.  Preyer,  of  Jena,  lately  brought  before  the 
Jena  Medical  Society  {Berlin.  JcUn.  Woch.,  May  5, 1884)  some  experiments 
on  guinea-pigs,  showing  that  the  temperature  could  be  easily  reduced  by 
this  method,  which  he  thinks  applicable  to  man.  He  used  a  spray  of 
simple  water,  and  found  that  the  rapidity  and  degree  of  the  effect  may 
be  regulated  by  varying  the  temperature  of  the  water  and  the  frequency 
of  its  employment.  Tlius,  when  the  temperature  of  the  water  used  was 
between  40°  and  45°  F.,  the  rectal  temperature  of  the  animals  was  re- 
duced about  two  degrees  within  from  five  to  ten  minutes.  If,  after  the 
discontinuance  of  the  spray,  the  minute  particles  of  water  entangled  in 
the  hair  be  allowed  to  slowly  evaporate,  the  temperature  continues  grad- 
ually to  diminish  for  several  hours.  If  water  at  the  temperature  of  70°  F. 
be  employed,  the  refrigeration  is  manifested  within  twenty  minutes,  but 
is  not  so  pronounced. 

Cold  drinks  reduce  the  heat  by  the  amount  that  is  necessary  to  raise 
them  to  the  temperature  of  the  body,  and  the  same  may  be  said  of  ice- 
liquids.  Cold  injections  would  act  in  the  same  direction  ;  some  effect 
may  thus  be  obtained,  though  not  very  much.  But  there  is  this  advantage 
about  the  introduction  of  cold  fluid,  that  it  does  not  seem  to  provoke 
the  reaction  that  occurs  when  it  is  applied  to  the  surface,  and,  therefore, 
the  reduction  obtained  is  not  neutralized  by  a  subsequent  rise.  Cold 
drinks,  consequently,  so  far  as  they  are  desired  by  the  patient,  are  as  use- 
ful in  febrile  cases  as  they  are  always  agreeable  ;  and  it  is  something  to 
wonder  at  that  the  earnest  desire  of  the  patient  should  so  often  have 
been  frustrated.     We  must  admit,  however,  that  cold  djinks  have  some- 


150  THERAPEUTICS    OF    THE    RESPIEATORY   PASSAGES. 

times  been  injurious  when  the  body  has  been  overheated,  and  there  are 
clinical  facts  and  even  physiological  experiments,  which  seem  to  show 
that  active  pulmonary  congestion  may  be  thus  induced.  Perhaps  it  was 
the  observation  of  such  cases,  and  of  some  other  evils  caused  by  drinking 
large  quantities  of  cold  water  by  overheated  persons,  which  brought 
about  an  undue  fear  of  cold  beverages. 

Cold  enemata  have  been  shown  bj'  Foltz  to  produce  a  distinct  fall, 
and  Rutenberg's  experiments  support  his  statements.  He  administered 
a  pint  at  a  time,  at  50°  to  55°  F.,  every  two,  three,  or  four  hours,  or  at 
longer  intervals  during  sleep,  if  the  temperature  had  fallen,  the  number 
given  during  the  progress  of  the  case  varying  between  thirty  and  three 
hundred. 

It  will  have  been  observed  that  it  is  in  Germany  that  cold  has  been 
most  thoroughly  and  systematically  tried.  The  method  has,  however,  ex- 
tended to  other  countries,  though  much  more  partially.  In  France,  for 
instance,  comparatively  few  have  adopted  it.  Fereol,  for  instance,  em- 
ploys it  in  grave  cases  ;  HomoUe  declares  it  is  not  a  specific,  but  thinks  it 
will  do  more  when  we  understand  better  the  conditions  in  which  to  use 
it  ;  Reynaud's  experience  was  rather  favorable  than  otherwise  ;  Dumont- 
pallier,  however,  completely  adopts  the  method,  and  Gignoux,  of  Lvons, 
has  lately  published  a  paper  '  giving  details  of  five  cases  of  grave  pneu- 
monia in  which  the  treatment  was  carried  out  with  a  resolution  equal  to 
that  of  German  authorities.  Four  of  the  patients  recovered,  and  M. 
Gignoux  thinks  very  highly  of  the  baths.  In  America,  Dr.  Austin  Flint 
admits  that  Liebermeister  was  justified  in  saying  that  typhoid  has  lost  a 
great  part  of  its  terrors.  In  England  there  has  been  no  enthusiasm,  and 
though  cold  has  been  tried  in  our  hospitals  it  has  hardly  been  so  fully 
tested  as  might  have  been  expected,  and  very  often  the  manner  in  which 
it  was  tried  would  have  been  pronounced  by  German  authorities  insuffi-: 
cient.  In  hyperpyrexia,  indeed,  considerable  confidence  is  felt  in  the 
plan,  and  as  no  other  holds  out  much  hope  of  success  it  is  thorouglily  car- 
ried out  ;  but  in  less  dangerous  cases  it  is  often  less  thoroughly  applied. 
Dr.  Collie,  in  the  Homerton  Hospital,  never  gave  more  than  three  baths  in 
the  twenty-four  hours,  none  of  which  were  longer  than  ten  minutes  and 
for  children  seven  minutes  ;  he  discontinued  bathing  at  the  end  of  the 
second  week  of  fever,  and  did  not  use  it  for  old  people  or  young  children. 
In  the  London  Fever  Hospital  the  bath  has  been  tried  in  many  cases  and 
satisfactory  results  reported.  Dr.  Cayley  admits  {Brit.  Med.  J.,  March 
1,  1884)  the  treatment  reduces  mortality  and  fulfils  the  physiological 
indications  and  produces  marked  alleviation  of  the  symptoms,  while  com- 
plications are  rendered  neither  more  frequent  ftor  more  severe.  Dr.  Af- 
fleck in  the  same  journal  (May  17th)  points  out  some  of  the  objections,  and 

'  Observations  de  Pneumonies  traities  par  les  baius  froids.     1884. 


ANTIPYRETICS.  157 

concludes  that  the  applicability  of  the  method  is  a  narrow  one,  and  he 
thinks  it  is  not  to  be  recommended  as  a  general  principle  of  treatment. 
In  exceptional  cases  and  in  the  rare  event  of  hyperpyrexia  he  would  cer- 
tainly employ  it.  Dr.  Ord,  with  anything  but  enthusiasm,  says  he  has 
not  known  harm  done  and  perhaps  in  some  cases  death  has  been  averted. 
While  Sir  W.  Jenner  states  that  the  published  records  have  not  carried 
conviction  to  his  mind  of  the  advantage  of  baths.  In  an  address  at  the 
Midland  Medical  Society'  (ISTO)  he  said,  respecting  typhoid,  "  while  ad- 
mitting, without  reserve,  that  heroic  measures  fearlessly  but  judiciously 
employed  will  save  life  when  less  potent  means  are  useless,  the  physi- 
cian whose  experience  reaches  over  many  years  will,  on  looking  back, 
discover  that  year  by  year  he  has  seen  fewer  cases  requiring  heroic  reme- 
dies, and  more  cases  in  which  the  unaided  powers  of  nature  alone  suffice 
for  affecting  a  cure  ;  that  year  by  year  he  has  learned  to  reg'ard  with 
greater  diffidence  his  ovvn  powers,  and  to  trust  with  greater  confidence  in 
those  of  nature."  Professor  Gairdner  has  even  gone  farther  and  con- 
demned the  system  {Glasgo%o  Med.  Jour.,  1878)  in  a  series  of  important 
cautions  in  respect  of  the  so-called  "  antipyretic  treatment  in  specific 
fevers." 

We  shall  not  discuss  here  the  ordinary  tonic  effects  of  small  doses, 
which  are  closely  allied  to  those  of  other  vegetable  bitters,  and  which 
have  been  sufficiently  alluded  to.  We  may,  however,  remark  that  per- 
haps the  simple  bitter  might  more  frequently  be  jDreferred  with  advantage, 
for  it  often  happens  that  even  small  doses  of  quinine  will  disagree  with 
the  stomach  when  other  tonics  will  not.  Moreover,  larger  doses  may  give 
rise  to  nausea  and  vomiting,  especially  when  the  mucous  membrane  is  ir- 
ritable, and  then  if  persisted  in  gastritis  may  be  set  up.  Sometimes  also 
it  irritates  the  intestinal  mucous  membrane.  No  doubt  it  is  easily  dis- 
solved in  gastric  juice  ;  but  perhaps  when  massive  doses  are  given  some 
of  it  may  pass  through  the  pylorus  especially  when  taken  in  powder. 
Even  in  solution  it  may  not  be-  all  absorbed  from  the  stomach  and  then 
the  alkaline  juices  would  precipitate  it.  The  biliary  acids  also  form  very 
insoluble  salts  with  quinia,  so  that  if  it  pass  into  the  duodenum  we  might 
expect  to  find  it  in  the  ffeces,  and  there  it  has  been  detected  ;  it  is  not 
precipitated  in  the  blood.  Although  this  fluid  is  alkaline,  probably  the 
carbonic  acid  holds  it  in  solution. 

On  the  blood  quinine  exercises  a  great  effect.  In  1867  Professor 
Binz  '  announced   that  it   had  a   direct  action  on  the  white  corpuscles, 

'  Binz :  Experimentelle  Untersuchung  liber  das  Wesen  der  Chininwirkung,  1867. 
Also  same  author's  Das  Cliinin,  nach  den  neuern  pharmacologischen,  1875,  and  nu- 
merous journal  articles  during  the  last  few  y&ars. 


158  THERAPEUTICS    OF    THE    EESPIRATORY    PASSAGES. 

checking  their  amoeboid  movements  and  arresting  their  tendency  to  pass 
tlirough  the  capillaries  in  inflammation.  There  seems  to  be  no  doubt  that 
it  checks  the  amoeboid  movements,  but  the  diapedesis  being,  like  the 
local  accimiulation  of  the  leucocytes,  a  consequence  of  the  inflammation, 
it  may  certainly  be  said  that  it  might  be  expected  to  cease  as  soon  as 
anvthing  arrested  the  inflammatory  process.  It  requires  a  toxic  dose  to 
act  on  the  white  corpuscles,  which  under  the  influence  of  such  an  amount 
diminish  in  number  sometimes  to  about  a  quarter.  The  red  globules 
have  been  said  to  be  enlarged  under  the  influence  of  quinia.  Manassein' 
observed  in  the  lower  animals  that  the  red  globules  were  lessened  in  size 
during  pyrexia.  In  this  state  quinine  restores  them,  but  so  with  other 
antip3'retics  ;  even  cold  will  do  this,  so  that  the  change  appears  to  be 
due  to  the  lessened  temperature  rather  than  to  any  direct  action  of 
quinine  on  the  corpuscles.  Binz,  however,  has  demonstrated  *  that  qui- 
nine lessens  the  ozonizing  power  of  tlie  blood,  and  to  this  property  some 
would  attribute  its  antipyretic  value  ;  but  such  interference  hardly  ac- 
counts for  all  the  reduction  of  temperature  and  the  antiseptic  influence 
of  the  alkaloid  must  be  of  considerable  importance.  The  effect  on  the 
ozonizing  power  is  seen  in  the  impediment  offered  to  the  action  on  guai- 
acum.  When  ozonized  oil  of  turpentine  is  dropped  into  tincture  of 
guaiacum  no  change  of  color  is  produced,  but  if  a  drop  of  blood  be  added 
it  strikes  a  blue  color  immediately,  because  the  blood  acts  as  a  carrier 
of  ozone  from  the  turpentine  to  the  guaiacum.  Now,  quinine  pre- 
vents this  reaction,  one  part  in  twenty  thousand  being  enough  to  cause 
a  perceptible  hindrance.  A  similar  impediment  to  the  reaction  of  in- 
digo, turpentine,  and  blood  also  occurs,  one  part  of  quinine  to  a  thou- 
sand of  the  mixture  delaying  the  characteristic  color-changes  from  green 
to  the  clear  yellow  of  isatin  for  about  an  hour.  Binz  has  shown  that  all 
the  salts  of  quinine  act  in  the  same  way,  and  that  the  action  is  on  the 
red  corpuscle — on  the  hnsmoglobin  ;  in  fact,  the  same  result  is  obtained 
when  crystallized  ha?moglobin  is  substituted  for  blood.  Accordingly  the 
theory  has  been  jiropounded  that  the  antipyretic  effect  is  due  to  the  im- 
pediment offered  to  the  ozonizing  power  of  the  blood,  but  this  seems 
scarcely  to  offer  us  a  key  to  all  the  medicinal  virtues  of  quinine.  A 
further  influence  on  the  blood  has  been  observed  :  it  retards  the  change 
to  the  acid  condition,  which  ordinarily  takes  place  in  shed  blood,  and 
which  Binz  regards  as  due  to  oxidation. 

Summing  up  the  effects  of  quinine  on  the  blood,  it  evidently  interferes 
with  oxygenation,  impairs  the  carrying  power  of  the  red  corpuscles  and 
hinders  them  from  supplying  oxygen  to  the  tissues,  while  it  also  impedes 

'  Ueber  die  Dimensionen  der  rothen  Blutkorperchen  unter  verschiedenen  Verhalt- 
nissen.     Berlin,  1873. 

'^  Archiv  f .  exper.  Path,  und  Pharmakologie,  1873. 


ANTIPYRETICS.  159 

the  function  of  the  leucocytes.  Pursuing  it  further,  we  find  that  it  re- 
duces the  nitrogenous  excreta — both  urea  and  uric  acid  beinar  consider- 
ably  lessened,  and  this  in  health  as  well  as  in  pyrexia.  Ranke,*  who  first 
noticed  this,  G.  Kerner,  Zuntz,  Rabuteau,  and  others  all  agree  in  this, 
though  they  differ  in  their  estimates  of  the  extent  to  which  it  occurs ; 
but  they  appear  to  have  experimented  with  different  quantities,  which 
may,  perhaps,  account  for  the  variations.  In  different  experiments,  with^ 
varying  doses,  the  decrease  of  urea  was  one-eighth,  one-fourth,  and  four- 
tenths  ;  of  uric  acid,  one-half  and  four-fifths.  It  might  have  been  antici- 
pated that  carbonic  acid  would  also  be  decreased,  but  this  has  not  been 
satisfactorily  shown  to  be  the  case.  This  reduction  of  nitrogenous  elim- 
ination being  accompanied  by  a  fall  in  the  temperature  points  to  dimin- 
ished metabolism.  Under  the  influence  of  quinine  the  tissues  receive 
less  oxygen,  or  else  are  rendered  incapable  of  incorporating  it,  or,  as  we 
might  say,  of  overcoming  its  affinity  for  the  corpuscles.  This  idea  is 
confirmed  by  other  facts  such  as  these,  that  quinine  arrests  many  fer- 
mentative changes,  hinders  fungi  from  absorbing  oxygen,  quenches  the 
phosphorescence  of  certain  infusoria,  and  destroys  the  ozonizing  power  of 
vegetable  juices.  Moreover,  in  an  atmosphere  of  ozone,  quinia  will  pre- 
vent the  peptonizing  of  albumen.  But  above  all  these  is  perhaps  what 
may  be  termed  the 

A7itiseptic  Action. — Dr.  J.  Pringle,  in  1750,  brought  before  the  Royal 
Society  some  "  experiments  on  septic  and  antiseptic  substances,  with  re- 
marks on  their  use  in  medicine,"  and  these  were  afterwards  added  to  his 
observations  on  "Diseases  of  the  Army,"  1704.  He  showed  that  cin- 
chona hindered  putrefaction,  but  he  thought  that  its  febrifuge  action 
must  differ  from  its  antiseptic  property,  on  account  of  the  rapiditv  with 
which  it  was  produced,  though  he  added  the  suggestive  remark  that 
all  the  medicines  which  he  had  found  useful  in  intermittents  were 
"powerful  correctors  of  putrefaction." 

The  discovery  of  quinia  in  1820  gave  a  great  impetus  to  the  neurotic 
hypothesis,  as  the  few  alkaloids  then  known  were  all  considered  to  be 
nervines  ;  but  Binz  has  returned  to  the  antiseptic  view  with  great  suc- 
cess. In  1867  he  showed  that  quinine  is  directly  poisonous  to  the  funo-i 
which  inhabit  various  fermenting  and  putrefying  liquids.  Colpoda  and 
paramecia  are  killed  by  a  solution  of  one  in  eight  hundred  immediately, 
they  die  in  a  few  minutes  in  a  solution  of  one  in  a  thousand,  while  one  in 
twenty  thousand  proves  fatal  after  a  few  hours.  Penicillium,  vibrios, 
and  bacteria  also  perish  in  the  presence  of  quinine,  but  for  the  last  two  a 
stronger  solution  is  required  to  kill  them.  One  per  cent.,  accordino-  to 
Bochefontaine,^  being  necessary,  and  some  resisted  this  for  a  long  time. 

'  Ranke :  Ueber  die  Ausscheidung  der  Harnsaure  beim  Menschen  im  physiol.  Zustande 
und  in  einigen  Krankheiten,  sowie  unter  dem  Einflusse  des  schwefelsauren  Cliinins. 
1858.  2  Archives  de  Pliysiologie,  1873. 


100  THERAPEUTICS    OF    THE    EESPIRATOKY    PASSAGES. 

In  1880  Krukenberg  found  organisms  which  died  after  a  few  hours'  ex- 
posure to  a  solution  of  one  in  one  hundred  thousand — a  solution,  said 
Binz,  at  the  International  Medical  Congress,  in  London,  in  1881,  "far  more 
dilute  than  that  furnished  by  our  blood  after  ordinary  doses  of  quinine." 
If  the  pyrexia-producing  process  is  closely  related  to  fermentation — 
Avhether  set  up  by  living  organisms  or  by  complex  chemical  compounds — 
we  might  anticipate  the  antiseptic  influence  to  be  important.  Accord- 
ingly Binz  and  his  followers  regard  this  explanation  of  the  antipyretic 
power  as  sufficient.  They  do  not  expect  quinine  to  act  as  a  fire  in  de- 
stroying microzymes,  but  if  it  enfeebles  them  they  anticipate  that  the 
task  will  be  completed  by  nature,  and  there  are  indications  that  time  is 
required  to  produce  the  effect.  Now,  in  this  respect  one  of  the  most  val- 
uable properties  of  quinine  is  that  it  remains  in  the  body  for  several 
hours,  and  further,  as  it  is  not  poisonous  to  human  beings  even  in  consid- 
erable amounts,  we  can  keep  up  its  influence  as  long  as  may  be  necessary. 
Further,  it  is  present  in  the  body  as  quinia,  and  perhaps  some  powerful 
disinfectants  do  not  act  as  antipyretics  simply  because  they  do  not  circu- 
late in  the  state  in  which  they  are  administered,  but  are  decomposed  as 
soon  as  they  are  swallowed,  while  others  cannot  be  used  because  they  are 
caustics  or  poisonous.  Again,  the  effect  of  alcohol  is  evanescent,  but 
arsenic  remains  for  along  time  in  the  system,  while  the  carbol  derivatives, 
though  they  distinctly  reduce  the  temperature,  are  apt  to  give  rise  to 
disagreeable  and  even  dangerous  symptoms.  They  are,  however,  cer- 
tainly antiseptics. 

It  is  difficult  to  deny  that  there  is  a  close  relation  between  the  power 
of  destroying  micro-organisms  out  of  the  body  and  the  remedial  value  of 
antiseptic  medicines.  But  the  action  may  not  be  precisely  the  same,  and 
some  observers  are  convinced  that  it  is  not.  Buchner '  estimates  that  for 
quinine  to  act  as  an  antiseptic  in  the  tissues  it  would  require  a  dose  of 
three  ounces  (I),  but  surely  the  estimate  of  Binz  is  more  reasonable  ;  for 
certainly  in  most  cases,  if  not  all,  we  should  only  have  to  make  the  blood 
an  unfavorable  fluid  for  the  growth  of  the  organisms,  and  we  know  that 
minute  quantities  of  antiseptics  will  effect  this.  With  so  powerful  a 
poison  as  corrosive  sublimate  we  may  well  fear  that  it  would  be  danger- 
ous to  attempt  to  introduce  enough  to  prove  fatal  to  organisms  in  the 
blood,  but  even  those  who  will  not  concede  that  it  acts  antiseptically 
have  been  constrained  to  admit  that  beneficial  results  have  been  obtained 
by  its  use.  Arsenic,  also,  a  very  powerful  poison,  though  with  slight 
claims  to  be  regarded  as  an  antiseptic  generally,  is  acknowledged  to  be  a 
most  powerful  anti-malarial  and  anti-periodic,  and  there  are  not  a  few 
who  believe  that  these  qualities  are  really  due  to  its  deleterious  influence 
on   bacteria.     We  must   admit,  however,  that   to    push   these  powerful 

1  Ceutralbl.  f.  kliu.  Med.,  1883. 


ANTIPYRETICS.  161 

poisons  to  the  extreme  in  deference  to  a  theory  as  to  their  anti-parasitic 
properties  would  be  a  practice  fraught  with  danger,  but  the  same  can 
scarcely  be  said  of  quinine  and  some  other  antiseptics  which  fulfil  the 
indication  suggested  above,  viz.  :  that  they  ought  to  be  capable  of  cir- 
culating in  the  blood  for  a  considerable  period  without  inflicting  serious 
injury  on  the  patient. 

Notwithstanding  all  that  can  be  said  in  favor  of  the  antiseptic  theory 
of  the  action  of  quinine,  it  does  not  satisfy  all  observers.  The  late  Pro- 
fessor Gubler  maintained  to  the  last  his  opinion  that  the  effect  of  quinine 
should  be  attributed  to  its  giving  tone  to  the  sympathetic  system. 
Others  are  content  to  refer  its  action  to  the  nervous  system  indefinitely. 
Gubler  regards  it  as  a  direct  stimulant  of  the  auditory  nerves,  as  well  as 
of  the  great  sympathetic  ;  Binz  says  it  produces  partial  anaemia  of  the 
brain,  a  view  directly  opposite  to  that  of  Briquet,  Hammond,  and  many 
others.  Dr.  Hammond's  experiments  at  the  time  seemed  to  me  to  show 
that  it  produces,  rather,  congestion  of  the  brain,  and  this  conclusion  is 
certainly  most  consonant  with  clinical  experience  when  it  is  given  in 
moderate  quantities.  The  noises  in  the  ears,  the  deafness,  the  sense  of 
fulness  in  the  head,  the  flushing  of  the  face,  and  other  symptoms  of  cin- 
chonism,  all  suggest  cerebral  congestion,  and  are  relieved  by  remedies 
appropriate  to  such  a  condition  and  sometimes  disappear  after  an  attack 
of  epistaxis  apparently  provoked  by  the  quinia.  The  effect  on  the 
spinal  cord  has  not  yet  been  satisfactorily  cleared  up. 

Briquet  found  that  large  doses  of  quinia  greatly  lowered  arterial  press- 
ure ;  when  he  injected  it  into  the  jugular  vein  in  full  quantity  it  instantly 
arrested  the  beat  of  the  heart  which  was  afterward  found  to  have  lost  all 
contractility,  the  left  side  being  full  of  scarlet  blood.  So  when  it  was 
thrown  into  an  exposed  heart  in  such  a  way  as  to  go  into  the  coronary 
arteries,  the  same  effect  was  produced  even  more  quickly.  When  a 
frog's  heart  is  immersed  in  a  solution  the  beats  at  once  become  slower, 
irregular,  and  soon  stop  altogether.  Large  doses  are  constantly  proved 
by  clinical  observation  to  lower  the  frequency  and  force  of  the  beat.  It 
may,  indeed,  become  rapid  and  feeble  after  toxic  quantities,  but  this  is 
only  an  evidence  of  cardiac  feebleness.  It  is,  then,  a  cardiac  sedative  in 
large  doses,  acting  by  depressing  the  heart-muscle  and  probably  its 
ganglia,  and  not  through  a  cardiac  centre  ;  collapse  would,  therefore, 
seem  to  be  a  probable  effect  of  poisonous  doses.  Small  tonic  doses  ap- 
parently exercise  no  perceptible  depressing  influence  ovir  the  circulation, 
but,  by  virtue  of  their  restorative  power,  rather  the  reverse. 

Large  doses  also  depress  the  respiration,  though  small  ones  may  per- 
haps accelerate  it.  In  fatal  cases  death  has  generally  seemed  to  be  due 
to  respiratory  and  cardiac  failure. 

Elimination  is  effected  chiefly  by  the  kidneys,  but  quinia  has  also 
been  detected  in  the  saliva,  the  sweat,  the  tears,  the  milk,  and  even  in  the 
11 


162  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

serum  of  dropsical  effusions.  Its  presence  in  the  sweat  may  perhaps  ac- 
count for  the  cutaneous  rash  which  sometimes  appears  ;  while  its  pres- 
ence in  the  milk  is  a  fact  of  some  clinical  import.  It  appears  in  the  se- 
cretion in  about  half  an  hour  after  it  has  been  taken,  and  the  elimination 
is  rather  slow,  lasting  for  two  or  three  days.  In  six  experiments  made 
by  Binz,  only  two-thirds  of  the  dose  was  excreted  in  forty-eight  hours  ; 
but  Dr.  L.  Thau,'  in  three  experiments,  recovered  nearly  the  whole  of  the 
alkaloid  in  the  first  forty-eight  hours,  so  that  most  of  the  remainder 
might  be  allowed  for  the  elimination  by  other  channels.  Dr.  Thau 
further  determined  the  rate  of  elimination,  finding  that  from  one-tliird 
to  a  little  less  than  half  escaped  in  the  first  six  hours,  and  about  three- 
fourths  was  eliminated  in  the  first  twelve  hours.  As  the  alkaloid  thus 
tarries  in  the  system  for  a  considerable  period,  it  is  obvious  that  the  dose 
should  not  be  repeated  too  often  ;  small  doses  are  constantly  given  more 
frequently  than  is  necessary,  and  massive  doses  should  certainly  only 
be  administered  at  considerable  intervals. 

Though  quinine  is  a  most  powerful  antipyretic  it  does  not  lower  verv 
much  the  temperature  in  a  healthy  person,  but  it  will  prevent  the  ordi- 
nary rise  of  temperature  caused  by  exercise.  Its  power  over  fever-heat 
is  now  generally  admitted,  a  committee  of  the  Clinical  Society  in  1870 
reported  ("Trans.,"  vol.  iii.)  that  it  had  a  very  decided  effect,  commencing 
in  from  one  to  two  hours  after  the  dose,  and  lasting  from  a  few  to  many 
hours.  The  large  doses  employed  in  Germany  cause  the  fall  to  com- 
mence early,  to  descend  far,  and  to  continue  for  a  long  time.  In  conse- 
quence of  the  lowering  of  temperature,  quinine  has  been  employed  in 
many  febrile  diseases,  and  may  be  tried  whenever  the  rise  becomes  se- 
rious, except  perhaps  in  inflammation  of  the  brain  and  its  membrane. 
In  typhus,  typhoid,  scarlatina,  acute  rheumatism,  erysipelas,  and  septic 
diseases  it  has  been  tried  again  and  again  in  varying  doses,  sometimes 
being  largely  used,  at  others  unduly  neglected.  The  massive  doses  in 
vogue  in  Germany  seem  to  have  been  first  resorted  to  by  W.  Yogt,'  who 
was  soon  followed  by  Wachsmuth,^  Liebermeister,  and  others.  The  last- 
named  author  considers  large  quantities  most  important  ;  e.g.,  he  gives  in 
typhoid  22  to  45  grains  at  once,  that  is,  he  may  divide  this  quantity  into 
three  or  four  doses  to  be  swallowed  at  intervals  of  ten  minutes,  and  he 
insists  generally  that  the  whole  of  it  must  be  taken  within  half  an  hour, 
or  at  the  utmost  within  an  hour,  and  he  considers  it  useless  to  look  for 
the  full  effect  if  it  is  extended  over  a  longer  time.  When  the  dose  is 
distributed  over  only  half  a  day,  the  reduction  of  temperature  is  rela- 
tively slight  ;  on  the  other  hand  he  does  not  repeat  such  a  dose  for  twenty- 


'  Thau  :  Die  Ausscheidiang  des  Chinins  beim  Gesunden  imd  Fiebemden.     1868. 
*  Vogt.  :  Schewizrische  Monatsschrift  f.  prakt.  Med.,  1859. 
'  Wachsmutb  :  Arcliiv  f.  Heilkunde,  1863. 


ANTIPTRETICS.  1G8 

four  and  usually  for  forty-eight  liours.  The  decline  of  temperature  goes 
on  for  from  six  to  twelve  hours,  then  a  rise  begins,  but  usually  it  does  not 
reach  the  previous  point  during  the  second  day.  Those  who  fear  this 
dose,  and  instead  of  30  grains,  for  instance,  give  two  doses  of  15  grains, 
do  not  meet  with  such  striking  results.  Liebermeister  stated  a  few  years 
ago  that  he  had  then  given  some  ten  thousand  doses  of  20  to  45  grains 
without  once  observing  any  injurious  effect.  Some  German  physicians 
have  gone  much  further,  but  his  maximum  at  that  time  had  been  45 
grains.  The  object  in  view,  he  considered,  is  to  reduce  the  temperature 
to  the  normal  point  or  near  it,  and  if  the  first  dose  does  not  accomplish 
this  he  increases  it,  but  if  it  brings  about  a  fall  below  the  normal — a  cir- 
cumstance not  uncommon — he  diminishes  the  amount  of  the  second  dose. 
Such  a  distinct  remission  of  the  fever  is  best  secured  by  giving  the  qui- 
nine at  night,  as  the  full  effect  then  reinforces  the  ordinarv  mornino-  fall. 
When  the  fever  is  abating  the  indication  for  quinine  is  much  less  than  in 
the  continuous  stage  ;  its  value  consists  in  its  power  to  produce  a  tempo- 
rary intermission,  and  when  that  already  exists  of  course  the  remedy  is 
less  distinctly  indicated.  Most  German  physicians  give  it  in  conjunction 
with  cold  baths  ;  it  obviates  the  necessity  of  administering  the  baths  so 
frequently,  and  the  reliance  placed  upon  it  may  be  estimated  by  Lieber- 
meister's  statement  that  if  he  were  compelled  to  the  disagreeable  alter- 
native of  adopting  either  cold  or  quinine  to  the  exclusion  of  the  other, 
he  would  mostly  take  the  quinine.  Should  the  stomach  be  unable  to 
tolerate  these  huge  doses  of  quinia  they  are  said  to  be  equally  effectual 
when  given  per  rectum. 

All  antipyretics  are  said  to  act  more  energetically  on  children  than 
adults,  but  German  physicians  give  quinine  very  freely  even  to  infants. 
Hagenbach  gives  to  children  under  two  years  of  age  from  10  to  15  grains  ; 
between  three  and  five  years,  15  grains  ;  between  six  and  ten  years  from 
15  to  23  grains  ;  between  eleven  and  fifteen  years  from  23  to  30  grains. 
Jiirgensen  reckons  a  grain  and  a  half  for  every  year  of  the  child's  ao-e 
up  to  five,  after  that  he  gives  from  7  to  15  grains.  With  very  high  fever 
he  advises  as  much  as  15  grains  to  a  child  in  its  first  year  and  75  grains 
to  an  adult,  and  says  that  he  has  repeatedly  resorted  to  both  these 
quantities. 

Quinine  will  abate  the  pyrexia  of  acute  rheumatism,  and  prior  to  the 
recent  use  of  salicin  in  this  disease  was  much  more  frequently  employed. 
In  what  perhaps  Germans  would  call  moderate  doses,  namely,  from  20 
to  30  grains  during  the  twenty-four  hours,  it  has  in  my  experience  kept 
down  both  the  temperature  and  the  pulse,  while  the  effect  on  the  joints 
seem  to  be  beneficial.  The  late  Dr.  Billing,  who  regarded  rheumatism  as 
a  neurosis,  relied  upon  quinine,  which  I  have  given  in  seven  to  ten  grain 
doses  three  times  a  day  for  weeks  together.  It  has  often  been  admin- 
istered in  pyfcmia,  but  without  much    effect,  though  many  seem  to  trust 


164  THERAPEUTICS    OF    THE    EESPIRATORY    PASSAGES. 

it  in  all  septic  diseases.  Its  marvellous  power  over  malarial  disease  is 
regarded  by  many  as  due  to  a  toxic  effect  on  a  bacillus.  As  soon  as  we 
admit  that  any  disease  is  caused  by  the  intrusion  of  a  micro-organism  it 
is  only  natural  to  anticipate  that  it  may  be  cured  by  a  medicine  which  is 
fatal  to  that  organism  ;  but,  as  already  insisted  on,  to  obtain  such  a  result, 
it  is  necessary  for  the  remedy  to  remain  long  enough  in  the  system,  and 
of  course  in  the  doses  required  it  must  not  be  injurious  to  the  patient. 
It  is,  further,  easy  to  understand  that  a  substance  which  is  fatal  to  some 
microzymes  may  have  no  effect  upon  others,  although  possibly  some  sub- 
stances may  be  found  to  be  poisonous  to  a  large  number  of  organisms. 
Quinine  will  not  cure  relapsing  fever,  and  we  find  that  the  spirilla  of  that 
disease  is  not  injured  by  the  alkaloid. 

In  respiratory  diseases  quinine  has  been  employed  both  as  an  anti- 
pyretic and  antiseptic.  Whooping-cough  has  often  been  thought  to  de- 
pend on  a  microzyme,  and  it  has  been  held  that  quinine  will  cure  it. 
Letzerich  announced,  in  1871,  that  he  had  found  a  fungus  in  the  lung  in 
whooping-cough.  Acting  upon  this,  Henke  employed  quinine  sprays  in 
hope  of  reaching  the  organism.  Helmholtz  proposed  to  treat  hay-fever 
by  a  snuff  containing  quinine,  which  certainly  sometimes  succeeds,  as  also 
does  a  solution  employed  with  a  syringe  or  douche.  The  local  effect  on 
the  mucous  membrane  is  by  some  credited  with  the  result,  rather  than 
any  influence  over  organisms.  But  other  antiseptics  seem  also  effectual 
in  this  disease. 

In  croupous  pneumonia  the  use  of  quinine  is  combined  with  baths 
by  most  German  physicians.  Jiirgensen  always  employs  the  two,  argu- 
ing that  quinine  reduces  the  temperature  without  injuring  the  heart, 
from  which  organ  the  chief  danger  is  to  be  apprehended,  since  death  usu- 
ally occurs  through  cardiac  insufficiency.  He  therefore  rejects  both  tartar 
emetic  and  veratria,  and  usually  also  digitalis,  on  account  of  the  danger 
of  collapse  from  their  effects  on  the  heart.  And  yet,  as  we  have  seen, 
Briquet's'  experiments,  which  were  made  on  dogs,  show  that  quinine  is  a 
cardiac  poison,  and  he  has  been  corroborated  by  Schlockow,'^  and  by  A. 
Eulenberg.^  Their  testimony  can  scarcely  be  put  aside,  though  Jiirgen- 
sen does  not  allude  to  it,  but  appears  to  take  it  for  granted  that  quinine 
is  a  tonic  to  the  heart.  But  assuredly  his  doses  are  not  tonic  ones.  He 
insists  positively  on  amounts  which  would  seem  to  incur  the  risk  of  being 
toxic.  Thus,  in  moderately  severe  pneumonia,  he  prescribes  30  grains  in 
solution,  and  in  severe  cases  75  grains,  and  even  this  he  does  not  regard 
as  the  limit,  and  these  quantities  he  orders  always  in  a  single  dose.  This 
is  often  followed  by  vomiting  ;  if  retained  for  half  an  hour  or  three-quar- 

'  Briquet :  Traite  tlierapeutique  dii  Quinquina  et  de  ses  Preparations.     Paris,  1853. 
*  De  Cliini  sulfurici  Vi  pliysiologica  nounuUa  Experimenta.    1860. 
'  Reicliert's  Archiv  f.  Auatomie,  1865. 


ANTIPYRETICS.  165 

ters,  he  considers  this  of  no  consequence,  as  most  of  the  alkaloid  will 
have  been  absorbed.  But  if  delay  seems  dangerous  he  repeats  the  dose, 
on  the  plea  that  it  is  better  to  give  too  much  than  too  little,  and  when- 
ever vomiting  occurs  in  a  quarter  of  an  hour  he  gives  a  second  dose, 
and  has  never  seen  any  injury  result.  Ice,  etc.,  may  be  used  to  allay  or 
prevent  vomiting.  In  order  to  obtain  the  full  effect  of  the  remedy  these 
huge  doses  need  only  be  given  every  second  evening  ;  but  nutrients  and 
wine  as  well  as  cold  baths  are  required  to  complete  the  treatment.  Very 
satisfactory  statistics  have  been  published  as  to  this  heroic  treatment,  but 
we  cannot  forget  that  pneumonia  is  a  disease  in  which  the  tendency  to 
recovery  should  not  be  overlooked,  and  in  which  masses  of  figures  may 
be  cited  to  demonstrate  the  success  of  the  most  opposite  methods  of 
treatment.  I  have  treated  pneumonia  by  moderate  doses  of  quinine, 
keeping  the  patient  slightly  under  its  influence,  and  when  further  anti- 
pyretics seemed  desirable,  have  used  aconite,  being  careful  all  along  to 
supply  nutrients,  but  not  necessarily  wine.  At  other  periods  I  have  tried 
the  stimulant  plan,  once  so  much  in  vogue,  and  still  earlier  venesection. 
I  have  not  yet  been  driven  to  resort  to  the  huge  doses  of  quinine  com- 
mended by  German  physicians. 

In  catarrhal  pneumonia  the  danger  arises  from  respiratory  rather 
than  from  cardiac  failure,  so  that  the  treatment  by  moderate  doses  of 
quinine  seems  to  be  rational,  and  aconite  may  be  employed,  when  it  is  also 
indicated,  to  restrain  the  heart,  but  the  use  of  nutrients,  of  respiratory 
stimulants,  and  other  adjuncts  may  be  essential.  But  what,  then,  shall  we 
say  of  cold  baths,  and  huge  quantities  of  quinine,  which  are  employed  by 
the  advocates  of  energetic  antipyretic  treatment  ?  If  quinine  depress 
the  respiration  so  much  that  in  poisonous  doses  death  seems  to  take 
place  from  failure  of  this  function,  is  there  not  a  risk  in  pushing  doses 
which  appear  to  be  dangerously  near  to  toxic  ones  ?  This  theoretical 
objection  seems  to  be  ignored  by  those  who  give  such  quantities,  but  they 
are  constrained  at  the  same  time  to  resort  to  cardiac  stimulants,  and  they 
insist  on  the  necessity  of  administering  wine  freely.  It  appears  to  me 
that  this  method  is  less  applicable  in  catarrhal  pneumonia  than  in  fevers, 
while  there  is  also,  to  my  mind,  a  strong  objection  to  formulating  so 
precisely  the  treatment  of  any  disease  ;  and  this  objection  is,  perhaps, 
more  forcible  in  reference  to  respiratory  diseases  than  to  the  specific 
fevers.  It  is  the  condition  of  the  patient  for  which  we  are  called  upon 
to  prescribe,  rather  than  the  nosological  position  under  which  his  suffer- 
ings may  be  grouped. 

In  phthisis  antipyretics  are  only  temporarily  useful  to  reduce  high 
temperatures,  and  quinine  is  the  only  one  to  which  we  need  resort. 
Small  or  moderate  doses  suffice  for  this  purpose,  and  it  is,  perhaps,  un- 
desirable to  give  it  continuously.  Digitalis  is  sometimes  employed, 
especially  in   Germany,  but  it  is  aj^t  to  irritate  the  gastric  mucous  mem- 


166  THEEAPEUTICS    OF   THE    RESPIEATOEY    PASSAGES. 

brane,  and  for  this  reason  is  unsuitable.  In  no  disease  do  we  more  need 
the  assistance  of  the  stomach,  which  is  too  apt  to  fail  us,  and  therefore 
whatever  interferes  with  its  function  is  likely  to  do  more  harm  than 
good.  Nutrients  must  form  the  foundation  of  all  treatment,  and  rest  or 
a  change  of  diet  will  suffice  very  often  to  put  on  one  side  the  suggestion 
of  an  antipyretic.  If  it  be  required,  a  mild  febrifuge  or  a  dose  or  two 
of  aconite  may  now  and  then  be  employed,  and  these  will  not  interfere 
with  digestion.  In  acute  miliary  tuberculosis  the  pyrexia  has  a  large 
share  in  the  phenomena,  and  cardiac  exhaustion  is  frequently  the  cause 
of  death.  Can  we  control  the  fever  ?  Quinine  seems  the  most  likely  an- 
tipyretic, and  has  been  most  frequently  employed,  except  alcohol.  But 
it  seems  useless  to  dwell  upon  the  appropriate  management  of  this  fatal 
disease. 

The  Salictl  Compounds. 

saiilcin,  salicylic  acid,  and  the  salicylates. 

We  are  certainly  indebted  to  Dr.  Maclagan  for  the  modern  revival  of 
the  use  of  salicin  as  an  antipyretic,  or  rather  as  a  specific  for  rheumatic 
fever.  His  earnest  advocacy  at  once  led  to  extensive  trials,  in  which  his 
statements  have  been  generally  confirmed,  and  of  course  the  extensive 
use  of  salicin  soon  led  to  the  employment  of  salic3'lic  acid  and  its  com- 
pounds, all  of  which  are  being  found  useful.  As  intimated  in  the  word 
revival,  salicin  is  not  a  novelty.  The  willow  has,  in  fact,  been  employed 
medicinally  from  early  ages.  The  Greeks  regarded  it  as  a  useful  astrin- 
gent, but  it  was  not  much  employed  in  modern  times,  except  as  a  popular 
remedy.  In  1763,  Mr.  Stone  communicated  to  the  Royal  Society  ("Phil. 
Trans.,"  vol.  liii.)  a  paper  on  the  use  of  salix  alba  as  a  remedy  for  agues, 
and  during  the  next  few  years  several  writers  published  their  views  on  its 
medicinal  value,  e.g.,  Meyer,'  Guenz,"  Koning,^  Hartman  and  Luders,* 
and  Akerberg.^  A  little  later  Dr.  S.  James '  introduced  into  practice  the 
broad-leaved  willow  bark  {salix  caprea  vel  salix  latifolia  rotunda)  and  pro- 
nounced it  to  be  a  most  admirable  substitute  for  cinchona.  His  state- 
ments were  confirmed  soon  afterward  by  White,'  who  had  employed  it 


'  Meyer,  I.  J.  :  De  salicis  fragilis  uso  medico.     1770. 

*  Guenz,  J.  W.  :  Disp.  II.  de  cortice  salicis  cortici  Peruviano  substituendo.     1772. 
^Koning,  P.  :  De  cortice  salicis  albse  ejusque  in  medicina  usa.     1778. 
^Hartmann,  P.  I.,  etLuders:  Diss,  de  virtute  salicis  anthelmintica.     1781. 

*  Akerberg,  M.  :  De  usu  corticis  salicis  in  Febribus  Intermittentibus.     1782. 

*  James,  S.  :  Observations  on  the  Bark  of  a  Particular  Species  of  Willow,  showing 
its  Superiority  to  the  Peruvian,  and  its  Singular  Efficacy  in  the  Cure  of  Ague,  Fluor 
Albiis,  Abscesses,  Hemorrhages,  etc.,  with  case.     1792. 

'  White,  W. :  Observations  and  Experiments  on  the  Broad-leaved  Willow  Bark. 
1798. 


ANTIPYRETICS.  167 

largely  in  intermittents.  Loeben  '  had  in  the  meantime  used  the  crack- 
•\jillo\v  [salix  fragilis)  in  putrid  fevers.  About  the  commencement  of 
tliis  century  G.  Wilkinson^  went  so  far  as  to  claim  for  the  willow  bark  a 
superiority  to  cinchona  ;  and  his  observations  and  cases  are  full  of  inter- 
est, although  it  must  be  confessed  he  failed  to  establish  his  conclusions. 
Salicin  was  obtained  in  an  impure  state  in  1835  by  Brugnatelle  and  Fon- 
tana,  and  Buchner,  1828.  Leroux  succeeded  in  1829  in  separating  the  al- 
kaloid pure.  It  has  been  found  in  several  species,  at  least  fourteen  of 
salix,  besides  eight  of  populus,  occurring  in  the  bark,  the  leaves,  and  the 
flowers.  At  intervals  from  this  time  for  about  forty  years  salicin  was 
commended  by  various  authors,^  and  obtained  no  little  repute  as  a  feb- 
rifuge, as  a  substitute  for  quinine,  and  as  an  antiperiodic.  It  was  also 
found  to  be  tonic  and  to  be  much  less  irritating  to  the  stomach  than  qui- 
nine, so  that  it  was  considered  as  not  unlikely  to  take  the  place  of  qui- 
nine should  that  alkaloid,  as  was  feared,  become  very  scarce.  The  wil- 
low bark,  besides  tonic  and  febrifuge  properties,  also  possessed  some 
astringency,  owing  to  the  presence  of  tannic  acid:  it  was  therefore  fre- 
quently classed  with  astringent  bitters,  and  besides  being  used  as  a  sub- 
stitute for  cinchona,  than  which  again  it  is  less  irritating,  it  was  employed 
in  derangement  of  the  digestive  organs  and  as  a  tonic  in  convalescence, 
and,  in  consequence  of  its  astringency,  also  in  chronic  mucous  discharges, 
and  even  in  passive  hemorrhage.  It  was,  moreover,  said  to  be  anthelmin- 
tic, and  occasionally  even  employed  as  a  local  astringent.  We  need  not 
be  surprised  that  with  such  a  history  the  willow  established  itself  in  some 
districts  as  a  popular  remedy,  and  Dr.  Maclagan  need  scarcely  have  gone 
to  a  colony,  or  even  to  a  malarial  district,  for  the  hint  which  he  turned  to 
so  good  an  account.  It  appears,  however,  to  have  fallen  into  disuse  by 
the  profession,  though  about  thirty  years  ago  it  was  partially  revived,  and 
I  then  saw  salicin  freely  tried  as  a  substitute  for  quinine.  It  was  then 
cheaper,  but  it  was  found  that  so  much  larger  doses  were  required  to 
produce    the    same   effect   that    its    employment   was  even  more  costly. 

'  Loeben,  J.  :  De  usu  corticis  Salicis  fragilis  variis  in  morbis,  prsecipue  in  Febribus 
putridis.     179B. 

^  Wilkinson,  G.  :  Observations  on  the  Cortex  Salicis  Latifolise.     1803. 

*  Desmartis,  T.  P.  :  Proprietes  medicinales  des  diverses  espece  de  Saules.     1852. 

Blaincourt,  J.  B.  :  Essai  sur  la  Saliciue  et  sur  son  emploi  dans  les  Fievres  Inter- 
mittentes.     1830. 

Besser,  O.  L.  Von  :   De  Salicinio.     1831. 

Richelot,  G.  :   Memoire  sur  les  proprietes  febrifuges  de  la  Salicine.     1833. 

Elliot,  V.  L.  :    Considerations  sur  la  Salicine  et  ses  proprietes  febrifuges.     1834. 

Kenzler,  B.  :    Experimenta  circa  Salicinse  virtutem  febrifugem.     1835. 

Blom,  P.  J.  :  Beobacht  und  Beitr.  liber  die  Salicine.     1835. 

Duhalde,  Halmagrand  et  Gaucheron,  MM. :  De  I'administration  du  Cyano-ferrure 
de  Sodium  et  de  la  Salicine  dans  les  Fievres  d'acc^s,  comme  succedan6  du  Sulfate  de 
Quinine.     1861. 


168  THERAPEUTICS    OF    THE    EESPIRATOET    PASSAGES. 

This,  no  doubt,  partly  contributed  to  its  again  being  neglected,  until  Dr. 
Maclagan  thoroughly  established  its  value.  % 

Salicin  is  decidedly  antipyretic  ;  it  is  easily  tolerated  by  the  stom- 
ach ;  it  remains  in  the  system  a  considerable  period  ;  it  is  also  anti- 
septic, and  probably  antiperiodic.  It  does  not,  at  any  rate  in  reason- 
able quantities,  produce  the  extreme  depression,  and  even  collapse, 
which  is  apt  to  occur  under  the  influence  of  salicylic  acid  and  its  salts. 
It  is  more  easily  tolerated  than  quinine.  We  can  scarcely  regard  it  as 
poisonous,  since,  according  to  Huseman  ("Die  Pflanzenstoffe  "),  Ranke 
took  three  ounces  in  the  course  of  three  days  without  suffering  any  incon- 
venience. Perhaps  his  specimen  was  not  very  pure,  for  certainly  much 
less  quantities  have  given  rise  to  toxic  symptoms,  including  rather  severe 
delirium.  Ordinary  medicinal  doses,  say  from  ten  to  thirty  grains,  if 
frequently  repeated,  will  soon  produce  noises  in  the  ears,  headache,  and 
giddiness.  But  toleration  is  very  soon  established.  I  have  taken  half- 
drachm  doses  every  hour  for  five  or  six  hours  in  succession,  and  then 
continued  the  medicine  at  longer  interval  for  some  days  ;  with  the  result 
of  reducing  a  high  temperature  and  rapid  pulse,  and  with  no  incon- 
venience except  singing  in  the  ears,  and  that  not  so  marked  as  when  pro- 
duced by  quinine,  though  it  continued  for  some  days  after  leaving  off 
the  medicine. 

Salicylic  acid  is  much  more  powerful  as  an  antiseptic.  Wagner  says 
it  is  more  active  than  carbolic  acid  as  a  disinfectant  for  application  to 
wounds.  The  presence  of  one  part  of  acid  in  two  thousand  will  arrest 
fermentation,  while  half  that  quantity,  one  in  four  thousand,  suffices  to 
check  the  amoeboid  movements  and  retard  the  outwandering  of  the 
white  blood-corpuscles.  A  proportion  of  one  in  a  thousand  produces 
stasis  in  the  vessels  and  destroys  the  leucocytes.  A  solution  of  one  per 
cent,  checks  the  action  of  ptyalin  on  starch,  while  in  artificial  digestion 
the  action  of  pepsin  is  greatly  interfered  with  by  the  presence  of  0.2  per 
cent.  The  acid  is  a  local  irritant,  and  as  such  is  very  apt  to  distress  the 
stomach  ;  it  is,  too,  rather  insoluble,  and  for  this  reason,  as  considerable 
doses  are  required,  often  given  in  powder  in  wafer  paper.  This  is  the 
easiest  mode  of  administration,  but  very  often  the  stomach  cannot  tol- 
erate it.  The  acid  is  the  quickest  of  the  salicyl  antipyretics  ;  it  is  much 
more  rapid  in  its  action  than  quinine,  though  the  effect  does  not  last  so 
long,  and  it  is  far  more  depressing.  After  a  very  transitory  stage  of 
excitement  the  fall  of  temperature  and  depression  of  the  heart's  action 
with  lowered  blood-pressure  and  relaxed  vessels  are  produced.  The  res- 
piration is  also  much  disturbed,  and  if  the  medicine  is  not  suspended 
collapse  may  ensue.  A  couple  of  doses  of  fifteen  to  twenty  grains  will 
often  bring  down  the  temperature  several  degrees  in  the  course  of  an 
hour  or  two. 

The  salicylates  are  much  less  irritating  to  the  stomach,  and  are  there- 


ANTIPYRETICS.  169 

fore  frequently  preferred  to  the  acid  ;  of  course,  the  salts,  as  such,  are 
neither  antiseptic  nor  disinfectant,  but  they  may  be  decomposed  in  the 
body,  when  the  free  acid  would  act  in  this  manner.  As  antipyretics 
they  are  nearly  as  powerful  as  the  acid,  and  much  more  easily  tolerated. 
The  salicylate  of  soda  is  most  commonly  used,  but  I  often  prefer  the 
potassium  or  lithium  salt — the  last  having  special  advantages.  Salicylate 
of  quinia  and  the  other  cinchona  alkaloids  have  also  given  me  satisfac- 
tion. The  salicylates  may  also  be  administered  alternately  with  quinine, 
or  a  single  large  dose  of  the  latter  may  be  employed  during  a  course  of 
frequent  doses  of  the  former,  for  in  order  to  obtain  their  full  effect  the 
salicylates  have  to  be  given  at  short  intervals. 

Just  as  in  the  case  of  quinine,  the  salicyls  have  very  little  effect  on  the 
temperature  in  health,  though  they  very  speedily  reduce  the  abnormal 
heat  in  fever.  Here  the  effect  is  rapid  ;  it  is  most  remarkable,  perhaps,  in 
acute  rheumatism,  though  in  other  febrile  states  it  is  also  very  marked. 
There  is,  however,  a  tendency  to  relapse  after  the  salicyls,  which  renders 
it  necessary  to  continue  the  remedy  for  some  time  after  the  relief  has 
been  obtained.  Moreover,  there  is  during  the  administration  a  danger  of 
collapse  being  brought  on  by  these  compounds,  except  in  the  case  of  sali- 
cin,  which  therefore  usually  deserves  the  preference. 

All  the  salicyls  are  readily  taken  up  into  the  system.  In  the  blood 
the  acid  would  almost  necessarily  become  salicylate  of  soda,  though  a 
portion  of  it  seems  to  unite  with  glycocol  to  form  salicyluric  acid.  It 
has  also  been  conjectured  that  some  of  the  acid  is  again  set  free  by  the 
carbonic  acid  of  the  blood-plasma  in  inflamed  parts,  and  so  acts  on  them 
locally  as  an  antiseptic,  but  this  is  quite  hypothetical.  In  the  intestinal 
canal  salicin  is  split  up  into  glucose  and  saligenin,  and  this  alkaloid  in  its 
turn  into  salicyluric,  salicylic,  and  salicylous  acids — the  last  of  which  is  a 
local  irritant. 

A  small  portion  of  the  salicyls  passes  away  by  the  sweat,  saliva,  bile, 
and  mucous  secretions,  but  the  principal  part  is  removed  by  the  kidneys. 
It  can  be  detected  in  the  secretion  in  about  ten  minutes  after  it  has  been 
taken,  and  the  elimination  goes  on  during  from  twenty-four  to  forty- 
eight  hours.  Thus  we  have  a  remedy  which  can  remain  in  the  system  for 
a  considerable  period,  a  point  of  no  little  importance  in  reference  to 
its  antiseptic  action.  It  might  have  been  thought  that  it  would  not  be 
necessary  to  give  such  frequent  doses  of  a  remedy  which  is  so  slow  to 
disappear,  but  as  the  elimination  begins  early  and  is  at  first  very  rapid, 
the  amount  circulating  in  the  system  is  speedily  reduced,  and,  moreover, 
the  liability  to  disagreeable  and  dangerous  symptoms  seems  to  forbid 
the  attempt  to  meet  the  circumstance  by  very  large  quantities  at  long 
intervals. 

Many  believe  that  the  antipyretic  properties  of  the  salicyls  are  due  to 
their  antiseptic  power  ;  if  so,  we  can  understand  why  the  acid  should  be 


170  THERAPEUTICS    OF   THE    EESPIKATORY    PASSAGES. 

the  most  potent,  for  locally  it  is  both  antiseptic  and  disinfectant,  and  for 
this  reason  it  would  naturally  be  preferred  in  sarcina  and  in  dyspepsia 
attended  by  putrefactive  changes  in  the  contents  of  the  stomach.  The 
effect  on  typhoid  and  other  fevers  may  also  be  attributed  to  a  destructive 
influence  on  organisms,  and  the  very  special  value  in  acute  rheumatism  is 
held  by  some  to  be  due  to  a  fatal  effect  on  a  microzyme,  to  the  presence  of 
which  they  attribute  this  disease.  And  certainly  the  action  is  something 
more  than  merely  antipyretic,  for  the  remedy  reduces  the  pain  as  well  as 
the  fever,  though  it  has  no  claim  to  be  called  an  anodyne  ;  it  also  reduces 
the  swelling  of  the  joints,  and,  in  fact,  relieves  the  mo-t  urgent  symptoms, 
so  that  it  may  be  said  to  cure  the  disease.  Yet,  as  we  have  said,  relapses 
are  apt  to  occur,  as  if  the  micro-organisms,  if  they  exist,  were  only 
"  scotched,"  not  killed.  As  an  antiperiodic  or  antimalarial,  perhaps  the 
effect  is  due  to  the  prevention  of  the  rise  in  temperature  which  forms  so 
important  a  feature  of  every  paroxysm  of  ague,  but  in  these  cases  quinine 
is  superior,  so  we  may  dismiss  Dr.  Maclagan's  hypothesis  as  to  the  willow 
flourishing  in  damp  situations,  where  rheumatism,  to  which  it  is  antidotal, 
is  also  rife.  Salicin  is  not  only  easier  to  take,  but  in  rheumatic  cases  very 
much  safer,  for  the  acid  and  its  salts  exercise  a  particularly  depressant 
action  on  the  heart,  and  we  know  that  in  rheumatism  this  organ  is  very 
likelv  to  suffer,  and  it  is  easy  to  understand  that  the  additional  depression 
caused  by  the  remedy  would  aggravate  the  danger.  Salicin  appears  to 
be  comparatively  devoid  of  the  tendency  to  produce  this  depression,  and 
can  be  given  in  full  doses  frequently  without  fear  ;  in  fact,  small  doses 
are  of  very  little  use. 

If  pneumonia  be  regarded  as  a  general  fever,  a  view  which  has  ob- 
tained, among  other  able  observers,  the  support  of  Austin  Flint,  who 
calls  it  "  pneumonic  fever,"  we  might  expect  that  the  salicjds  would  prove 
valuable  antipyretics  in  this  disease,  and  as  the  antiseptic  action  is  most 
obvious  in  the  acid,  it  would  be  natural  to  prefer  it.  In  diphtheria  we 
can  obtain  a  local  effect  on  the  throat,  as  we  can  also  in  scarlatina  ;  but 
then  it  would  interfere  with  the  use  of  iron,  which  is  sometimes  so  urgent. 
The  mouth  and  throat,  however,  may  be  cleansed  by  the  acid,  locall}^  ap- 
plied, in  either  of  these  diseases,  and  the  internal  use  will  reduce  the  tem- 
perature. But  in  diphtheria  the  antipyretic  effect  is  not  usually  urgent. 
Other  forms  of  sore  throat  are  often  relieved  by  the  salicyls,  as  are  also 
hay-fever  and  influenza  ;  in  these  also  it  may  be  employed  locally  as  well 
as  internally,  or  salicylic  acid  may  be  used  topically  while  salicin  is  given 
internally.  In  the  recurrent  pyrexial  attacks  in  the  course  of  phthisis 
salicin  may  also  be  used,  but  the  acid  is  too  depressant  and  quinine  is 
almost  always  to  be  preferred. 

Salicylic  acid  is  rather  insoluble,  and  therefore  mucilage  is  often  em- 
ployed to  suspend  it  in  water.  Glycerine  is  a  convenient  solvent  and  will 
take  up  thirty  or  forty  grains  of  the  acid  in  the  ounce,  and  when  hot 


ANTIPYRETICS.  171 

sixty  grains  ;  the  glj-cerine  can  be  diluted  with  warm  water  at  the  time 
of  use.  A  solution  of  from  one  to  two  grains  in  the  ounce  will  keep 
pretty  well,  and  is  also  effective  locally.  In  giving  it  internally  it  is 
well  for  the  acid  to  be  pretty  freely  diluted,  which  can  be  accomplished 
by  using  the  glycerine  mixed  with  water,  a  drachm  to  the  ounce,  in- 
structing the  patient  to  drink  some  water  after  it.  The  salts  are  freely 
soluble  and  possess  a  sweetish  taste,  which  some  do  not  object  to  ;  sali- 
cin  is  decidedly  bitter,  not  very  soluble,  but  can  be  given  in  water  or  in 
wafer  paper. 

Kairik. 

During  the  last  two  years  much  has  been  written  respecting  this 
substance,  which  appears  to  be  both  a  certain  and  potent  antipyretic, 
and,  perhaps,  in  proper  cases,  when  cautiously  given,  it  may  be  consid- 
ered as  safe,  but  its  action  certainly  varies  in  different  individuals,  so 
that  the  proper  dose  for  each  has  to  be  ascertained  by  careful  observation 
at  the  connnencement.  Moreover,  as  some  of  the  concomitant  efifecto 
are  such  that  the  patient  should  be  constantly  watched  while  under  its 
influence,  it  seems  to  be  most  adapted  for  hospital  practice,  where  there 
is  no  difficulty  in  taking  the  temperature  every  hour  or  two.  Kairin  is 
described  as  the  hydrochloride  of  oxyethyl — quinolin-hydride,  or  as  a 
methyl  hydrate  of  oxyquinolin,  having  the  formula  CjoII^gNO.  It  is  a 
derivative  of  quinolin,  and  is  said  to  exist  under  two  forms,  viz.  :  Icairin, 
which  is,  perhaps,  more  durable  and  more  agreeable  in  its  effect,  and 
kairin  M.,  which  appears  to  have  been  the  more  extensively  used. 

Kairin  was  discovered  by  Dr.  O.  Fischer,  of  Munich,  about  two  years 
ago,  and  was  introduced  as  an  antipyretic  by  Dr.  Filehne,  Professor  of 
Physiology  at  Erlangen,  who  has  employed  it  in  all  febrile  conditions, 
including  pneumonia  and  phthisis.  He  gives  it  in  doses  of  4  grains  in 
wafer  paper,  directing  water  to  be  freely  drank  after  it,  but  for  the  first 
three  or  four  doses  double  the  quantity,  8  grains.  The  temperature 
is  reduced  about  one  degree  by  each  full  dose,  and  as  soon  as  it  falls 
to  100°  F.  half  doses  only  are  given,  because  if  altogether  discontinued 
the  temperature  again  rises  rapidly,  with  perhaps  a  rigor,  but  when  the 
smaller  doses  are  continued  only  a  gradual  rise  occurs.  Should  a  rigor 
take  place,  a  dose  of  8  grains  is  immediately  given.  In  feeble  subjects 
smaller  quantities  suffice,  say  two  or  three  grains,  but  in  some  persons 
8  grains  may  fail  to  produce  satisfactory  reduction,  and  then  more  may 
be  given,  13  or  even  16  grains  per  hour  for  three  or  four  doses,  but  to  be 
discontinued  as  soon  as  the  temperature  falls  to  100°  F.  By  careful  ob- 
servation during  the  first  day  the  proper  dose  for  any  individual  may 
be  determined,  for  the  system  does  not  get  accustomed  to  the  remedy, 
neither  has  any  cumulative  effect  been  observed. 


172  THERAPEUTICS    OF    THE    RESPIRATOEY    PASSAGES. 

Dr.  Girat  has  experimented  largely  on  animals,  and  finds  that  kairin 
lowers  the  temperature  very  constantly,  while  it  also  retards  the  pulse  and 
respiration  ;  he  injected  it  hypodermically,  and  found  that  the  member 
operated  upon  was  paralyzed,  the  sensibility  of  the  part  was  blunted, 
and  sometimes  complete  anaesthesia  took  place.  The  kairin  is  eliminated 
chiefly  by  the  kidneys,  and  its  presence  in  the  secretion  may  be  detected 
in  twenty-five  minutes  after  the  dose,  and  under  its  influence  the  urine 
acquires  a  dark  green  color.  This  effect  is  also  produced  upon  man  by 
its  clinical  use ;  discoloration  sets  in  in  about  twelve  hours  and  lasts 
twenty-four  hours.  Dr.  Girat  determined  the  toxic  dose  to  range  between 
one  and  two  grains  per  pound  of  the  animal's  weight. 

Dr.  Paul  Guttmann  {Jierlin.  Jclin.  Wbch.,  1884)  has  employed  kairin  in 
86  cases,  in  doses  of  7  to  15  grains.  It  speedily  reduced  the  temperature, 
which  in  many  cases  fell  to  normal  within  four  hours,  the  reduction  being 
accompanied  usually  by  profuse  sweating.  Sometimes  vomiting  was 
produced,  and  occasionally  singing  in  the  ears.  His  cases  included  pneu- 
monia, phthisis,  pleurisy,  measles,  scarlet  fever,  and  other  febrile  dis- 
eases. The  sweating  was  particularly  observable  in  cases  of  phthisis. 
The  unpleasant  symptoms  were  less  noticed  when  the  kairin  was  freshly 
prepared,  but  some  specimens  which  had  been  kept  produced  not  only 
disagreeable  but  even  alarming  symptoms,  such  as  cyanosis  and  collapse. 
We  may  remark,  however,  that  such  accidents  have  occurred  when  the 
quality  of  the  drug  could  be  in  no  way  impugned.  For  example,  Frey- 
muth  found  in  several  cases  severe  gastric  disturbance  and  prostration, 
compelling  him  to  discontinue  the  remedy.  So  did  Seifert,  as  well  as 
Riegel,  and  even  Filehne  has  met  with  similar  inconveniences. 

Dr.  Gottlieb  Merkel  treated  nineteen  cases  of  phthisis,  pleurisy,  car- 
ditis, scarlet  fever,  and  typhoid  with  kairin  exclusively,  the  patients  being 
from  sixteen  to  fifty-two  years  of  age.  These  cases  confirm  the  antipy- 
retic power,  and  he  seems  so  to  have  regulated  the  use  as  to  have  avoided 
disagreeable  or  dangerous  symptoms,  but  he  finds  the  greatest  benefit 
when  neither  the  heart  nor  the  lungs  are  affected. 

Dr.  Hallopeau  has  employed  it  in  pneumonia  and  phthisis,  and  con- 
siders the  antipyretic  effect  to  be  certain,  but  the  question  remains 
whether  such  an  effect  is  desirable  in  these  cases.  Dr.  Menche  cannot 
recommend  it,  for  he  several  times  observed  collapse  to  be  brought  on  in 
phthisis  and  pneumonia,  though  he  had  better  results  in  rheumatism,  in 
which  he  thinks  it  might  take  the  place  of  salicylate  of  soda.  So  Dr. 
Korach  (Deut.  3fed.  Zeit.)  met  with  severe  collapse  in  pneumonia  and 
typhoid,  though  he  admits  the  antipyretic  influence. 

Professor  Riegel  reported  {Allg.  Med.  Central  Zeit.,  July,  1883)  un- 
satisfactory results  in  pneumonia  ;  he  obtained  but  slight  reduction  of 
temperature  by  four  half-gramme  doses  (seven  and  one-half  grs.)  at  inter- 
vals of  one  hour,  and  even   larger   quantities  were  comparatively  power- 


ANTIPYRETIC  S.  173 

less.  When  the  temperature  fell  to  normal  it  often  rose  again,  in  spite 
of  repeated  doses,  and  the  pulse,  though  reduced  in  power,  was  not  in 
frequency.  Instead  of  the  patient  feeling  better,  as  described  by  Filehne, 
severe  depression,  almost  amounting  to  collapse,  often  rendered  it  neces- 
sary to  resort  to  stimulants,  and  he  therefore  concludes  that  it  is  a  dan- 
gerous remedy,  especially  in  asthenic  cases,  chiefly  on  account  of  its  de- 
pressing action  on  the  heart.  In  a  later  communication  {Centralblatt  f. 
Klin.  Med.,  November,  1883)  he  repeats  these  objections,  and  states  that, 
in  consequence  of  the  frequently  threatened  collapse,  he  has  given  up  the 
use  of  kairin  in  pneumonia,  in  which  he  finds  the  antipyretic  effect  so 
slight,  and  in  which,  moreover,  the  danger  does  not  arise  from  the  high 
temperature.  His  statements  are  corroborated  by  Seifert  and  L.  von 
Hoffer  {Centralblatt).  The  latter  gave  muriate  of  kairin  in  pleurisy,  peri- 
carditis, pneumonia,  tuberculosis,  and  fevers,  and  found  it  uncertain.  In 
pneumonia,  rigors  and  profuse  sweats  disturbed  his  patients  ;  in  tubercu- 
losis he  considers  it  contra-indicated,  as  the  temperature  only  fell  for  a 
short  time  and  afterward  rose  higher  than  before,  this  rise  being  accom- 
panied by  heavy  perspirations,  rigors,  and  collapse.  He  also  mentions 
cyanosis  and  burning  of  the  forehead  as  disagreeable  effects  sometimes 
noticed,  but  he  never  saw  the  digestive  system  interfered  with.  He  con- 
cludes that  in  feeble  persons  it  should  only  be  given  with  caution. 

We  have  but  few  observations  by  English  physicians  at  present,  but 
no  doubt  they  will  soon  accumulate.  Dr.  Ashby,  of  Manchester,  reports 
{Brit.  Med.  J.,  December,  1883)  that  in  a  case  of  typhoid  in  a  child  of  ten 
years  two  two-grain  doses  always  reduced  the  temperature  two  degrees. 
Dr.  Carter  {Liverpool  Med.-Chir.  Jour.,  January,  1884)  mentions  a  case  of 
hyperpyrexia  in  rheumatic  fever  in  which  kairin  gave  favorable  results. 
Dr.  Archer,  of  Liverpool,  has  recorded  {Brit.  Med.  J.,  April  12,  1884)  a 
case  of  enteric  fever  treated  with  kairin,  with  the  observations  on  te"mper- 
ature,  pulse,  and  respiration  taken  at  the  time  by  his  resident  officer,  Dr. 
Oldham.  His  case  is  said  to  have  been  "  manifestly  a  desperate  one " 
on  admission  to  hospital,  and  although  the  patient  died  the  temperature 
was  greatly  influenced  by  the  remedy,  and  "  on  two  or  three  occasions, 
when  he  was  about  to  die,  kairin  apparently  seemed  to  have  a  great  in- 
fluence in  assisting  to  resuscitate  the  flagging  vital  powers,  and  we  had 
some  hope  of  rescuing  him." 

Kairin  appears  to  have  no  claim  to  be  an  antiperiodic,  even  larger  doses 
fail  to  cut  short  ague,  and  Cohn  andZadek  {Deut.  Med.  Woch.)  were  un- 
able to  prevent  the  rise  of  temperature  in  remittents  by  giving  the  dose 
at  the  beginning  of  the  exacerbation  and  repeating  it  hourly.  In  re- 
lapsing fever,  however,  full  doses  appear  to  prevent  the  relapses,  but 
gastric  disturbances  and  prostration  are  apt  to  follow.  A  very  interest- 
ing observation  has  been  made  by  Freymuth,  who  found  that  kairin  had 
no  effect  upon  the  spirilli  of  relapsing  fever,  although  it  reduced  the  tern- 


174  THERAPETJTICS    OF    THE    RESPIRATOEY    PASSAGES. 

perature,  showing  apparently  that  this  last  effect  is  not  dependent  on  an 
antiseptic  or  germicide  action. 

Chixolix  or  Quinolin. 

This  derivative  of  quinine,  chinchonin,  or  aniline,  is  a  mobile,  refract- 
ing liquid,  lately  introduced  as  antipyretic  and  antiseptic.  It  forms 
definite  salts  and  the  tartrate  and  salicylate  have  been  employed  in  doses 
of  five  to  ten,  and  even  fifteen  grains.  Externally  quinolin  is  a  disinfect- 
ant, and  a  five  per  cent,  solution  has  been  used  to  paint  the  fauces,  or 
as  a  gargle  in  diphtheria.     Internally  the  dose  is  three  to  ten  minims. 

Resokcin, 

named  from  being  first  derived  from  a  gum  resin,  galbanum,  and 
isomeric  with  orcin,  which  is  derived  from  archil,  is  another  recent  in- 
troduction, possessing  similar  properties  to  quinolin,  being  a  disinfectant 
externally,  two  to  ten  per  cent,  solutions  being  used,  and  these  are  not 
irritant,  although  resorcin  itself  is  a  caustic.  It  may  be  applied  to  the 
fauces  in  diphtheria  either  by  painting  with  a  solution  or  as  a  spray. 
Resorcin  is  a  meta-dihydroxyl-benzol,  a  neutral  crystalline,  white  body. 
It  is  now  obtained  from  carbolic  acid.  It  is  freely  soluble  in  water,  alco- 
hol, and  ether.  Internally  it  reduces  the  temperature  and  pulse  in 
pyrexia,  but  does  not  affect  the  normal  temperature.  Excessive  doses 
give  rise  to  singing  in  the  ears,  deafness,  mental  disturbance,  tremors, 
and  other  nervous  symptoms.  Above  one  drachm  it  is  poisonous,  but  that 
amount  has  been  given  as  a  single  dose  ;  usually  from  seven  to  ten  grains 
every  .two  hours  suffices.  The  t£|,ste  being  somewhat  pungent,  it  should 
be  well  diluted. 

Veratria 

is  a  very  powerful  alkaloid  possessing  exceedingly  irritating  proper- 
ties, and  more  adapted  for  external  than  internal  use  ;  nevertheless,  it 
has  been  employed  as  an  antipyretic,  for  it  reduces  the  temperature, 
weakens  the  circulation,  and  retards  respiration.  It  is  a  powerful  poison 
to  the  cardiac  muscle,  as  well  as  to  its  ganglia,  and  it  depresses  both  the 
cardiac  and  respiratory  centres.  A  minute  dose  is  said  to  quicken  the 
pulse  and  raise  the  blood-pressure,  but  after  a  full  dose  there  is  an  im- 
mediate fall  in  the  number  of  the  heart-beats,  as  well  as  in  the  arterial 
pressure.  In  pyrexia  the  fall  of  the  temperature  may  amount  to  several 
degrees  Fahrenheit,  but  this  is  apt  to  be  accompanied  by  vomiting,  pros- 
tration, syncope,  and  collapse.  Seeing  that  minute  doses  retard  the  res- 
piration,   even    after    section    of    the    pneumogastrics,   we    must    admit 


ANTIPYRETICS.  175 

with  Bezold  and  Hirt  that  it  is  a  direct  depressant  of  the  respira- 
tory centre  in  the  medulla,  eventually  killing  it.  It  seems  to  have  been 
first  employed  as  an  antipyretic  by  W.  Vogt,  followed  by  Liebermeister, 
who  in  typhoid  prescribes  one-twelfth  of  a  grain  in  a  pill  every  two 
hours,  and  says  that  from  four  to  six  such  doses  suffice.  He  does  not 
consider  the  collapse  which  so  often  ensues  as  dangerous,  and  says  that 
it  is  easily  controlled  by  restoratives  and  stimulants.  Jiirgensen  avoids 
this  alkaloid  in  pneumonia,  because  he  regards  the  collapse  as  due  to  the 
effect  on  the  heart,  the  failure  of  which  is  so  often  the  great  danger  in 
this  disease.  Veratria  is  so  much  inferior  to  aconite  and  other  remedies 
less  dangerous  and  less  disagreeable  that  I  altogether  exclude  its  inter- 
nal use  from  my  own  practice.  Taylor  mentions  ("  On  Poisons,"  1875) 
a  case  in  which  one-sixteenth  of  a  grain  had  been  taken  in  a  pill,  and 
the  patient  was  soon  afterward  "  found  insensible,  the  surface  cold,  the 
pulse  failing,  and  there  was  every  symptom  of  approaching  dissolution." 
The  patient  ultimately  recovered,  but  remained  some  hours  in  a  doubt- 
ful condition.  Yet  larger  doses  than  this  have  often  been  prescribed, 
but  the  case  certainly  justifies  the  opinion  that  it  is  wiser  to  reject  this 
alkaloid  as  an  internal  remedy. 

Digitalis. 

Wunderlich  seems  to  have  introduced  the  use  of  digitalis  as  an  anti- 
pyretic. Thomas,  Ferber,  and  Liebermeister  soon  followed.  They  give  as 
much  as  ten  to  twenty  grains  in  the  course  of  thirty-six  hours,  and  fol- 
low it  up  by  a  full  dose  of  quinine,  thirty  to  forty-five  grains,  and  this 
has  sometimes  succeeded  when  quiijine  alone  failed  in  reducing  the  tem- 
perature. The  indication  for  its  use  as  an  antipyretic  is  directly  oppo- 
site to  that  in  heart  disease.  The  more  frequent  the  pulse  the  less  is 
digitalis  indicated.  The  German  physicians,  who  have  chiefly  used  it, 
consider  that  in  patients  with  powerful  action  of  the  heart  no  harm  is 
done  if  it  cause  nausea  and  vomiting,  but  as  soon  as  it  does  so  the  medi- 
cine should  be  stopped.  In  pneumonia  it  has  also  been  used,  but  the 
effect  upon  the  heart  is  late,  and  we  therefore  fail  to  get  it  just  when  we 
want  it,  while  if  we  give  large  doses — and  these  are  necessary  to  reduce 
the  temperature — collapse  is  apt  to  come  on  just  at  the  period  of  defer- 
vescence. Any  one  who  has  met  with  that,  says  Jiirgensen,  will  not  be 
anxious  to  repeat  the  experiment,  though  he  thinks  that  when  the  heart 
is  vigorous  it  may  be  safely  employed  to  reduce  the  temperature. 

As  a  cardiac  regulator,  not  as  a  febrifuge,  small  doses  at  considerable 
intervals  may  be  useful  in  pneumonia,  as  well  as  in  other  diseases,  but 
while  in  this  case  we  avoid  the  paralyzing  influence  on  the  heart  we  lose 
the  effect  on  the  temperature.  For  either  purpose  I  regard  it  as  vastly 
inferior   to  aconite,  which   is  more   certain   and  less   dangerous.     There 


176  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

seems  to  me  to  be  little  if  any  physiological  basis  for  the  use  of  digitalis 
as  an  antipyretic,  while  the  clinical  evidence  is  not  fully  satisfactory.  A 
careful  study  of  Wunderlich's '  cases  will  show  that  the  medicine  was 
often  given  in  such  a  manner  that  its  action  was  produced  about  the 
period  of  the  normal  decline,  and  so  far  they  fail  to  carry  conviction  that 
the  fall  was  produced  by  the  treatment.  The  various  effects  of  digitalis 
in  different  doses — the  fact  that  it  is  in  one  case  a  cardiac  tonic  or 
stimulant  and  in  another  a  depressant,  that  its  action  is  confessedly 
slow,  and  that  at  the  best  it  is  uncertain,  leads  me  to  prefer  either  aco- 
nite or  quinine,  according  to  the  cases,  to  the  almost  total  exclusion  of 
digitalis. 

In  bronchitis  it  has  been  used  to  support  the  heart,  but  other  things 
are  quicker  in  their  action  as  well  as  more  certain,  so  that  here  again 
we  may  regard  it  as  either  unnecessary  or  dangerous.  In  hcBmoptysis 
arising  from  heart  disease  the  use  of  digitalis  can  be  understood,  and  per- 
haps it  may  be  admissible  when  this  symptom  is  due  to  the  congestion  of 
incipient  phthisis,  provided  always  that  the  circulation  is  languid  and 
there  are  other  indications  for  its  use.  Some  venture  to  give  it  in  fully 
developed  phthisis,  particularly  in  combination  with  quinine,  but  here 
again  the  small  quantities  in  which  it  is  employed  are  incapable  of  affect- 
ing the  temperature,  and  it  must  be  regarded  rather  as  a  cardiac  remedy. 
Further,  it  is  very  liable  to  derange  the  digestion,  unless  in  minute  quan- 
tities, and  certainly  in  phthisis  it  is  of  the  highest  importance  to  dispense 
with  anything  which  is  likely  to  interfere  with  nutrition.  The  value  of 
digitalis  in  phthisis  was  urged  at  the  beginning  of  this  century  by  Bed- 
does,*  Kinglake,'  and  others.  It  has  continued  to  be  employed  more  or 
less  down  to  the  present  time.  Quite  recently  Dr.  Jacobi  stated,  at  the 
Medical  Society  of  the  State  of  New  York  {Medical  Record,  February 
23,  1884),  that  he  seldom  treats  a  case  of  phthisis  without  it.  But  it  is 
not  as  an  antipyretic  he  employs  it,  but  rather  for  the  effect  on  the  heart 
and  indirectly  on  nutrition.  It  is  therefore  in  small  doses  combined 
with  other  remedies,  such  as  iron,  nux  vomica,  arsenic,  etc.,  that  it  has 
been  most  generally  used  and  is  most  likely  to  be  of  service  in  phthisis. 
Thus  it  will  be  seen  that  in  all  respiratory  diseases  the  administration  of 
digitalis  must  be  regulated  by  the  condition  of  the  heart.  In  fact,  we  re- 
gard it  as  a  cardiac  regulator,  and  consider  the  benefits  which  appear  to 
have  followed  its  use  as  due  to  this  action,  directly  or  indirectly. 

'  Wunderlich  :  Manual  of  Medical  Thermometry. 

'  Beddoes,  T.  :  Observations  on  the  Management  of  the  Consumptive,  on  the  Pow- 
ers of  Digatalis  Purpurea,  and  on  the  Cure  of  Scrofula.     London,  1801. 

^  Kinglake,  R. :  Cases  and  Observations  on  the  Medical  Efficiency  of  Digitalis  Pur- 
purea in  Phthisis  Pulmonalis.     1801. 


ANTIPYKETICS.  177 


Aconite. 

Greek  writers  often  speak  of  a  poison  named  aconite  (o.kov'ltov),  and 
Dioscorides  describes  (lib.  iv.,  cap.  77,  78)  two  kinds,  but  not  in  such  a 
way  as  to  enable  us  to  identify  the  plants  to  which  he  refers.  Latin 
poets  seem  to  have  used  the  word  as  a  synonym  for  poison.  The  genus 
to  which  aconite  belongs  is  very  numerous.  DecandoUe  included  one 
hundred  and  seven  varieties  in  twenty-two  species.  The  aconitum  pan- 
iculatum  was  once  adopted  by  the  London  and  Dublin  pharmacopoeias, 
but  it  is  probably  inert,  for  Christison  having  raised  it  at  Edinburgh, 
from  seeds  supplied  to  him  by  DecandoUe,  found  this  plant  destitute  of 
medicinal  properties.  It  is  doubtful,  indeed,  how  far  aconitum  panicula- 
tum  was  ever  employed,  for  Pereira  could  not  find  a  sample  in  commerce, 
nor  was  he  able  to  obtain  a  single  specimen  except  such  as  had  been 
grown  in  botanical  gardens. 

The  aconitum  napellns  is  now  the  only  official  plant. 

Baron  Stoerck,'  in  1702,  wrote  an  essay  on  this  and  other  vegetable 
medicines,  from  which  may  perhaps  be  dated  the  introduction  of  aconite 
into  use.  It  is  true  that  some  of  his  statements  were  much  exaggerated 
and  were  even  disputed  at  the  time,  especially  in  reference  to  conium, 
but  many  of  his  observations  are  worthy  of  consideration,  though  we 
must  admit  that  no  value  attaches  to  his  cases  of  cancer,  which  he  re- 
ported as  cured  and  which  his  contemporaries,  four  or  five  years  after, 
tell  us  all  died  of  the  disease.  Manghin  ^  sums  up  some  of  the  prop- 
erties of  aconite  in  a  letter  to  Stoerck.  Andreas  ^  proposed  it,  in  1768,  as 
a  remedy  in  arthritic  diseases,  in  which  he  was  soon  after  supported  by 
Spielmann/  and  a  little  later  by  the  Abbe  Mann.^  Several  other  publica- 
tions on  the  subject  appeared  in  the  same  century,  after  which  there  was 
a  lull  in  the  literature  and  the  medicine  seems  to  have  fallen  into  compara- 
tive disuse.  But  in  1835,  Dr.  Turnbull "  again  called  attention  to  the 
value  of  aconite  in  painful  nervous  affections,  with  an  enthusiasm  which 
seems  to  have  caused  distrust  rather  than  confidence.      In  1844,  the  Ed- 

'  Stoprck,  Baron  A.:  LibeUns  qno  demonstrator  Stramoninm,  Hvoscyamum.  Aco- 
nitum tuto  exhiberi  usu  interno,  et  remedia  esse  in  multis  morbis  maxima  salutifera. 
Vienna,  176^. 

^  Mangliin  :  Epistola  ad  Stoerck  de  Aconito.     Vienna,  1766. 

"  Andreas,  J.  F.  :  De  usn  sahitari  Extracti  Aconiti  in  Arthritide,  observationibus 
comprobato.     1768. 

^Spielmann,  S.  A.  :  De  Aconito.     1769. 

^Mann,  M.  L'Abbe  :  The  Extraordinary  Cure  of  the  Gout  by  Hemlock  and  Wolfs- 
bane.    Trans,  by  P.  Thicknesse.     1784. 

^Turnbull,  A.  :  On  the  Preparation  and  Medicinal  Employment  of  Aconitine  by  the 
Endermic  Method  in  the  Treatment  of  Tic  Douloureux  and  other  Painful  Affections. 
London,  1835. 

12 


178  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

inburjrh  Senatus  Academicus  awarded  a  ijold  medal  to  Dr.  Alexander 
Fleming'  for  an  inquiry  into  the  properties  of  aconite.  This  essay  was 
published  the  following  year,  and  has  continued  to  be  regarded  as  a 
valuable  contribution  to  therapeutics  down  to  the  present  time.  He  rec- 
ommended aconite  in  neuralgia  of  all  kinds,  in  diseases  of  the  heart,  in 
rheumatism,  in  erysipelas,  carcinoma,  etc.  It  is  curious  that  both  be- 
fore and  since  a  similar  wide  field  for  its  use  has  been  claimed.  Thus, 
as  we  have  seen,  Stoerck  recommended  it  in  cancer,  Andreas  in  gout, 
others  employed  it  in  inflammation,  and  Marcello,''  somewhat  later,  as  a 
substitute  for  depletion  in  fevers,  both  continued  and  intermittent.  No 
doubt,  as  we  shall  see,  its  anodyne  influence  when  employed  locally  led  to 
its  use  in  painful  diseases,  while  internally  its  febrifuge  power  caused 
it  to  be  employed  not  only  in  pyrexia,  but  whenever  the  pulse  was  fre- 
quent, whence,  perhaps,  its  repute  in  some  cardiac  diseases.  My  own  ex- 
perience of  its  use  dates  from  my  entrance  into  the  profession,  since  as 
soon  as  I  became  a  pupil  T  found  that  my  revered  teacher,  the  late 
William  Huxtable,  had  been  employing  it  in  a  large  practice  for  many 
years,  and  continued  daily  to  prescribe  it. 

WheD  given  to  animals  aconite  produces  muscular  weakness,  causing 
them  to  stagger,  vascular  depression,  sometimes,  but  not  often,  vomit- 
ing, perhaps  convulsions,  and  eventually  death.  There  is  also  general 
anaesthesia,  as  was  often  demonstrated  on  dogs  by  the  late  Dr.  Pereira, 
at  the  London  Hospital.  If,  however,  too  large  a  dose  be  given,  the 
animal  may  be  killed  so  quickly  that  the  amijsthesia  is  not  observed. 
Death  may  occur,  apparently  from  paralysis  of  tlie  heart,  in  less  than  a 
minute  after  a  li^-podermic  injection  of  aconitia.  On  opening-  the  thorax 
immediateh^  after  death  Pereira  found  that  there  was  no  pulsation  of  the 
heart  visible,  but  Fleming  states  that  he  has  seen  it  continue  to  beat  for 
some  time.      Similar  effects  are  produced  on  most  animals. 

In  cases  of  accidental  poisoning  in  man,  the  first  symptom  has  usually 
been  burning-  or  tingling  in  the  mouth  "and  throat,  followed  by  a  similar 
sensation  in  the  extremities,  which  rapidly  spreads  to  the  trunk.  The 
pulse  is  greatly  depressed  and  later  becomes  weak,  irregular,  or  inter- 
mittent, and  at  last  cannot  be  felt  ;  respiration  is  also  slow,  feeble,  shallow, 
irregular,  and  at  last  arrested.  There  is  great  prostration  from  loss  of 
muscular  power.  The  general  sensibility  is  also  reduced,  so  that  with  the 
tingling  sensations  more  or  less  cutaneous  anaesthesia  is  noticed.  There 
is  great  anxiety,  but  the  intellect  usuallv  remains  clear  to  tlie  last.  The 
voice  is  reduced  to  a  whisper  and  sometimes  the  special  senses  are  lost. 

'  Fleming.  A.  ;  An  Inquiry  into  the  Physiological  and  Medical  T^rnpjrties  of  Aco- 
nitumNapellus,  to  which  are  added  Observations  on  several  other  Species  o '  Aconitum. 
London,  1845. 

■^  Marcello,  C.  :  Dell'  nso  dell'  Aconito  Napello  nelle  Febbri  Continue  ed  Intermittenti 
irritative,  come  surrogato  al  Salasso  ed  al  sanguisugio.     1856. 


ANTIPYRETICS.  179 

All  this  time  the  temperature  steadily  falls.  The  muscular  weakness 
seems  to  be  due  to  depression  of  tlie  motor  nerve-endings  which  gradu- 
ally extends  to  the  cord.  The  sensory  nerve-endings  are  also  affected  and 
the  paralysis  extends  inward,  as  it  does  also  when  the  j^oison  is  locally 
applied.  Sometimes  the  symptoms  of  poisoning  come  on  almost  imme- 
diately, but  in  other  cases  a  considerable  delay  has  been  observed.  Such 
variations  are  probably  due  to  differences  of  dose  or  of  the  preparation 
and  to  the  condition  of  the  stomach  with  regard  to  food.  A  number  of 
cases  have  occurred  in  which  the  root  has  been  taken  in  mistake  for 
horse-radish.  As  some  time  would  naturally  elapse  before  absorption 
when  the  poison  was  thus  taken  with  a  meal,  it  is  not  surprising  that 
symptoms  should  not  appear  for  three-quarters  of  an  hour  ;  though  when 
the  tincture  has  been  taken  on  an  empty  stomach  the  effect  has  been 
almost  immediate. 

Many  years  ago  I  was  called  to  a  young  lady  aged  twenty  years,  who 
had  swallowed  a  dose  of  aconite  liniment  in  mistake  for  some  drops 
which  she  had  been  accustomed  to  take  for  hysteria.  A  very  violent 
paroxysm  of  that  malady  had  occurred  in  the  evening,  and  a  dose  of  the 
supposed  remedy  was  administered.  The  stomach  was  empty  at  the 
time,* and  she  complained  immediately  of  a  burning  in  the  throat  ;  in  a 
very  few  minutes  tingling  of  the  lips,  mouth,  and  throat  was  felt,  and  she 
said  that  her  hands  and  feet  had  both  gone  to  sleep.  Within  an  hour 
this  characteristic  symptom  had  spread  over  the  whole  surface,  and  there 
was  distinct  loss  of  sensation  ;  the  pulse  was  slow  and  gradually  became 
weak,  and  later  still  irregular  and  scarcely  perceptible  ;  the  respiration 
was  feeble,  infrequent,  and  gradually  became  shallow  and  irregular  ;  the 
diminution  in  the  general  sensibility  gradually  increased,  the  voice  was 
reduced  almost  to  a  whisper,  a  cold  clammy  sweat  stood  upon  the  sur- 
face ;  there  was  extreme  anxiety,  great  muscular  weakness,  no  convul- 
sion, no  spasm,  no  pain,  no  vomiting.  The  intellect  was  perfectly  clear. 
The  horizontal  position  was  strictly  enforced  and  stimulants  freely  em- 
ployed, but  she  continued  in  a  state  of  peril  for  nine  or  ten  hours. 

It  will  be  observed  that  in  many  respects  the  symptoms  produced  by 
aconite  are  the  opposite  to  those  caused  by  digitalis,  which  has  there- 
fore been  employed  with  a  certain  amount  of  success  as  an  antagonist. 
Dr.  Milner  Fothergill's  experiments  on  this  subject  seem  to  show  that 
digitalis  may  be  useful  as  a  protective  "  if  given  in  sufficient  dose  and  a 
sufficient  time  (from  five  to  nine  hours)  before  the  dose  of  aconitine  is 
administered  "  {Brit.  Med.  Journ.,  August,  1877). 

The  effects  of  medicinal  doses  closely  resemble  those  produced  by 
larger  quantities  ;  thus  locally  aconite  causes  numbness  or  tingling,  or  a 
sensation  often  called  "  pins  and  needles."  It  lowers  the  sensibility  to 
touch  and  temperature,  no  doubt  through  its  powerful  depressing  influ- 
ence on  the  sensory  nerve-endings.     If  a  portion  of  the  root  be  chewed. 


180  THERAPEUTICS    OF    THE    RESPIRATORY"  PASSAGES. 

or  a  drop  of  the  tincture  placed  on  the  tongue,  a  similar  sensation  ex- 
tends over  the  lips,  mouth  and  throat.  Full  therapeutical  doses  reduce 
the  pulse  in  frequency,  force,  and  tension  ;  they  also  retard  the  respira- 
tion and  cause  a  feeling  of  weakness  with  the  characteristic  tingling  of 
the  extremities.  As  the  pulse  falls,  the  skin  flushes  and  becomes  moist. 
Besides  this  diaphoresis  the  medicine  may  also  cause  some  diuresis.  If 
the  dose  be  repeated  or  have  been  at  first  very  large  the  effect  on  the 
heart  is  more  serioi^s,  and  appears  to  be  due  to  a  direct  action  on  the 
organ  ;  the  pulse,  instead  of  having  fallen  about  ten  beats,  may  have 
been  reduced  fifteen  or  twenty,  and  become  smaller,  weaker,  quicker,  and 
eventually  irregular.  Muscular  debility  is  now  extreme,  respiration 
shallow  and  hurried,  or  sometimes  sighing  ;  chilliness  is  complained  of, 
the  extremities  are  cold,  prostration  profound  ;  if  the  patient  attempt  to 
sit  up,  giddiness,  confusion  of  sight,  or  syncope  occur,  and  the  heart 
ceases  in  diastole.  In  all  cases  of  an  overdose,  the  horizontal  position 
must  be  maintained,  as  there  is  great  danger  that  on  attempting  to  sit 
xip,  fatal  syncope  may  occur.  All  these  symptoms  may  occur  from  what 
have  been  sometimes  described  as  full  therapeutical  doses,  but  it  is  most 
desirable  that  such  quantities  should  very  rarely  be  used,  for  a  very  large 
experience  of  this  remedy  convinces  me  that  all  its  good  effects  may  be 
obtained  without  running  the  risk  of  producing  grave  physiological  ef- 
fects. 

The  symptoms  produced  by  full  doses  of  aconite  begin  early  and  con- 
tinue for  a  considerable  time.  A  full  medicinal  dose  will  affect  the  pulse 
and  produce  other  symptoms  in  from  fifteen  to  thirty  minutes,  sometimes 
even  earlier.  The  influence  reaches  its  height  in  from  one  to  two  hours  ; 
it  diminishes  slowly,  so  that  there  is  but  little  decrease  for  three  or  four 
liours  more,  but  after  that  the  symptoms  gradually  subside,  though  a 
degree  of  lassitude  remains  for  several  hours  longer.  If  the  dose  be  very 
large,  or  if  a  second  dose  should  be  administered  before  the  effect  of  the 
first  passes  off,  the  effects  will  be  still  more  marked,  the  pulse  may  fall  to 
forty  or  even  lower,  but  it  soon  rises  and  becomes  at  the  same  time  small, 
weak,  and  irregular  ;  the  resjDiration  also  becomes  shallow  and  hurried  ; 
sometimes  sickness  appears,  with  intense  prostration,  headache,  giddiness, 
and  interferences  with  or  loss  of  special  senses.  These  effects  may  last 
thirty-six  or  forty-eight  hours.  It  may  now  be  well  to  consider  the  mode 
of  its  action  on  different  systems. 

On  the  circulation,  as  we  have  seen,  the  effect  is  very  decided.  It  de- 
presses the  heart  by  a  direct  action  on  its  structure  or  on  its  ganglia  ; 
for  the  action  has  been  shown  to  be  produced  on  the  frog's  heart  after 
its  removal  from  the  body,  and  on  the  application  of  the  drug  to  the  sur- 
face of  the  heart  the  usual  phenomena  are  observed  ;  after  action  of  the 
vagi  and  in  atropinized  animals  the  symptoms  of  poisoning  also  occur. 
Perhaps  the  retardation  of  the  pulse  may  depend  on  two  influences,  one 


ANTIPYRETICS.  ISl 

in  the  heart  itself,  the  other  in  the  medulla.  Dr.  J.  B.  Nunneley  was 
unable  to  detect  any  alterations  in  the  vessels  of  the  frog's  web  ("  Proc. 
Royal  Soc,"  1870),  and  Achscliarumow  {Reicherfs  Archiv,  18GG)  found, 
after  dividing  the  sympathetic  in  the  neck,  that  galvanizing  the  periph- 
eral end  produced  the  usual  phenomena  even  in  the  most  advanced  stages 
of  poisoning  by  aconite.  Thus  the  drug'  seems  not  to  affect  the  vasomo- 
tor nerves — a  conclusion  confirmed  by  other  experiments.  Nevertheless, 
impulses  cannot  be  transmitted  from  the  periphery  to  the  vasomotor  cen- 
tres, as  the  poison  destroys  the  conducting  power  either  of  the  afferent 
nerves  or  of  the  cord. 

This  brings  us  to  a  consideration  of  the  effects  on  the  nervous  system, 
on  which  very  divergent  views  have  been  held.  It  is  not  improbable  that 
great  differences  in  the  alkaloid  or  other  preparations  employed  have  viti- 
ated some  of  the  experiments.  Even  in  toxic  quantities  loss  of  sensa- 
tion occurs  before  serious  disturbance  of  respiration,  and  long  before  loss 
of  voluntary  motion  dogs  will  walk  about,  follow  their  master,  answer  to 
their  names,  and  wag  their  tails  wlien  anesthesia  of  the  surface  is  so  com- 
plete that  they  are  insensible  to  pinching  or  pricking  with  needles. 
Liegeois  and  Hottot  (Journ.  de  Physiol.,  1861),  from  very  complete  exper- 
iments on  frogs,  conclude  that  the  aui^sthesia  is  produced  by  jiaralyzing 
first  of  all  a  sensory  perceptive  centre  above  the  cord,  and  secondly,  the 
peripheral  extremities  of  the  nerves,  which  last  effect  afterward  extends 
to  the  nerve-trunks.  Loss  of  sensibility  in  frog's  legs  was  simultaneous 
with  or  even  preceded  disturbance  of  respiration,  and  occurred  not  only 
long  before  the  loss  of  voluntary  motion,  but  even  while  reflex  activity 
remained  intact.  The  api)licatlon  of  aconitia  to  a  nerve-trunk  paralyzes 
its  sensibility,  but  when  the  veins  of  a  frog's  leg  are  tied  and  the  drug 
injected  into  the  artery,  the  skin  loses  its  sensibility  long  before  the  nerve 
is  affected.  When  voluntary  movements  are  at  length  prevented  Lie- 
geois and  Hottot  ascribe  this  effect  to  the  centre  rather  than  to  paralysis 
of  the  motor  trunk,  because  irritation  of  the  nerves  induces  contractions 
of  their  muscles  ;  but  the  motor  trunks  must  be  somewhat  affected,  for 
the  local  application  of  aconite  suspends  the  conducting  powers,  and  after 
death  their  sensitiveness  is  lost  earlier  than  normally. 

In  the  respiratory  system  the  effect  of  aconite  is  well  marked  and 
comes  on  early.  The  action  appears  to  be  on  the  centre  of  which  it  is  a 
direct  depressant,  for  arrest  occurs  in  tlie  frog  before  the  motor  nerves 
become  affected,  and  previous  section  of  the  vagi  does  not  prevent  the 
effect  of  the  poison  on  the  respiration.  The  fall  in  the  temperature  in  a 
fatal  case  recorded  by  Achscharumow  amounted  to  three  degrees  Cent. 

The  effect  on  the  muscular  system  sometimes  amounts  to  complete 
prostration.  Tremors  and  nervous  twitching  are  rare  ;  partial  or  com- 
plete loss  of  voice  is  not  uncommon  j  muscular  debility  may  pass  off  in 
a  few  hours  or  may  last  several  days. 


182  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

Alimentary  System. — A  sensation  of  warmth  in  the  epigastric  re- 
gion is  common  enough,  and  nausea  and  even  vomiting  have  been  ob- 
served. Christison  mentions  (''On  Poisons")  that  he  had  observed  grip- 
ino-  and  diarrhoea,  and  others  have  spoken  of  an  irritant  action  on  the 
alimentary  canal,  but  this  must  be  very  rare  even  when  toxic  doses 
have  been  taken,  and  I  have  never  known  it  to  occur  from  medicinal 
doses. 

On  secretion  the  effect  is  only  moderate.  Stoerck  and  others  ascribe  to 
it  diaphoretic  and  diuretic  qualities,  and  these  it  certainly  possesses. 
Most  authors  admit  that  it  is  somewhat  sudorific.  As  soon  as  the  circu- 
lation is  depressed,  perspiration  is  likely  to  break  out.  The  diuretic  ac- 
tion is  much  less  evident,  and  cannot  be  turned  to  any  practical  account, 
elimination  probably  occurs  chiefly  through  the  kidneys,  and  is  rather 
slow,  as  may  be  supposed  from  the  long  time  which  the  effects  continue. 
Perhaps  some  portion  may  be  carried  off  by  the  skin,  for  an  eruption  has 
occasionally  been  observed  to  make  its  appearance.  It  may  lay  claim  to 
be  in  some  circumstances  an  emmenagogue,  as  under  its  influence,  given 
for  other  purposes,  the  menstrual  flow  is  often  restored. 

If  we  call  to  mind  the  manner  in  which  diuresis  and  diaphoresis  occur, 
on  the  fall  of  the  pulse  and  temperature,  it  will  not  be  surprising  that 
secretion  generally  may  be  promoted  by  any  medicine  which  produces 
such  fall. 

The  chief  use  of  aconite  is  as  a  febrifuge  to  reduce  arterial  action  and 
lower  temperature  ;  a  subsidiary  use  is  to  allay  pain  and  spasm,  as  well  as 
to  abate  excitation  of  sensory  nerves.  H.  C.  Wood  says  that  he  has 
never  used  it  "  in  those  cases,  such  as  pneumonia,  in  which  a  sudden  and 
very  powerful  effect  is  desired,  simply  because  veratrum  viride  seemed  to 
him  safer,  more  readily  controlled,  and  equally  effective."  This  state- 
ment is  just  the  reverse  of  what  I  should  make  respecting  these  two 
druo-s.  Perhaps  our  experience  differs,  because  each  has  learned  to  trust 
to  one  drug  almost  to  the  exclusion  of  the  other.  He  admits  as  to  verat- 
rum that  "  in  practice  it  should  simply  be  used  to  lessen  the  force  of  the 
circulation,"  and  further  on  he  says,  "  When  true  sthenic  arterial  excite- 
ment is  to  be  combated  in  any  disease,  except  it  be  gastritis,  veratrum 
viride  may  be  employed  as  a  prompt,  thoroughly  efficient,  and  at  the 
same  time  very  Safe  remedy — very  safe,  since  it  is  almost  incapable  of 
producing  death  in  the  robust  adult,  unless  used  with  great  recklessness 
and  in  repeated  doses.  In  the  early  stages  of  sthenic  pneumonia,  it 
offers,  I  believe,  the  best  known  method  of  reducing  temperature  and  the 
pulse  rate,  and  of  ameliorating  the  disease."  This  is  almost  the  kind  of 
statement  that  I  could  indorse  with  regard  to  aconite,  and  then  it  would 
not  be  necessary  to  exclude  gastritis  ;  but  one  point  should  be  constantly 
remembered,  viz. :  that  it  is  quite  unnecessary  to  give  what  have  been 
called  full  therapeutical  doses.      Much   better  results  are  obtained  from 


ANTIPYRETICS.  183 

repeated  small  doses,  and  as  soon  as  distinct  effects  are  produced,  the 
medicine,  as  I  have  long  taught,  should  be  suspended  or  given  at  longer 
intervals. 

I  have  been  in  the  habit  of  prescribing  aconite  in  numerous  diseases 
for  the  last  thirty  years.  In  the  first  edition  of  my  work  on  Sore  Throat, 
1861,  from  the  result  of  many  hundred  cases,  I  strongly  recommended 
it  in  febrile  and  inflammatory  diseases  ;  at  that  date  I  entered  a  caution 
as  to  the  dose,  which  in  all  the  text-books  was  overstated.  Admitting 
it  to  be  true  that  a  single  dose  of  five  minims  or  more  of  the  tincture 
might  be  administered  with  benefit,  I  urged  that  repeated  doses  of  much 
smaller  amount  are  more  advisable.  The  strength  of  the  British  officinal 
tincture  is  only  about  a  third  of  that  of  the  former  London  Pharmacopoeia, 
but  still  the  officinal  dose  is  too  large,  except  under  rare  circumstances  ; 
two  minims  can  be  repeated  three  or  four  times  a  day,  but  as  a  rule  a 
single  minim  will  suffice.  In  rare  cases  three  may  be  required,  but  the  ef- 
fect should  be  watched.  Aconite  is  not  adapted  for  use  in  single  large 
doses,  after  the  manner  in  which  some  antipyretics  are  now  employed, 
and  any  attempt  to  use  it  in  this  way  is  likely  to  lead  to  serious  conse- 
quences. But  in  full  doses,  at  moderate  or  short  intervals,  after  the 
fashion  of  saline  febrifuges,  there  is  no  more  valuable  remedy.  A  cau- 
tious use  of  this  medicine  is  devoid  of  danger,  though  if  recklessly 
pushed  it  may  undoubtedly  destroy  life — rapidly  and  unexpectedly,  for 
toxic  symptoms  develop  themselves  rather  suddenly,  if  the  first  indica- 
tions of  its  action  be  unheeded.  In  fact,  it  is  a  cumulative  poison,  and, 
consequently,  is  not  to  be  prescribed  in  increasing  doses.  All  the  good 
effects  may  be  obtained  by  small  quantities,  repeated  at  longer  or  shorter 
intervals,  according  to  the  rapidity  of  the  action  desired.  I  stated 
in  18G1  that,  although  I  had  used  it  in  thousands  of  cases,  I  had  never 
produced  alarming  symptoms  of  poisoning,  and  knew  no  medicine  which 
less  frequently  disappointed  my  expectations.  Further,  I  said  I  had  given 
it  once,  twice,  and  thrice  a  day  for  a  considerable  time,  every  four, 
three,  two  hours  for  a  shorter  time  ;  and  sometimes  repeated  a  dose  every 
half  hour,  carefully  watching  the  patient.  Others  have  since  claimed 
great  credit  for  the  discover)/  that  a  dose  may  be  given  every  quarter  of 
an  hour  ! 

After  a  few  doses,  sometimes  after  a  single  one,  the  action  of  the  drug 
is  observed,  the  pulse  is  reduced  in  frequency  and  power  ;  in  sotne  cases 
the  power  is  increased,  the  frequency  diminished.  The  skin  becomes  re- 
laxed and  bedewed  with  a  gentle  perspiration,  nervous  irritability  and 
excitement  are  allayed,  a  calm  comes  over  the  patient,  and  often  a  sound 
sleep  returns  after  a  long  absence.  The  pain  is  relieved  almost  as  cer- 
tainly as  when  it  is  locally  applied  for  neuralgia.  Clearly,  then,  it  is  a 
valuable  sedative,  exercising  a  marked  influence  over  the  heart.  It  was 
some  appreciation  of  these  properties  which  caused  it  to  be  recommended 


18-i  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

in  heart  disease  and  acute  rheumatism.  If  a  drop  of  the  tincture  be  placed 
on  the  tongue,  it  is  found  to  be  acrid  and  bitter,  and  this  taste  is  soon  fol- 
lowed by  a  numbness  or  tingling  in  the  mouth  and  fauces.  Now,  when  the 
full  action  is  produced,  in  giving  this  medicine,  a  similar  sensation  to  this 
is  perceived  in  other  parts ;  The  j^atient  will  declare  or  complain  that  he 
feels  "  numbed,"  or  that  he  has  the  "  pins  and  needles,"  or  that  he  feels 
"just  as  if  his  feet  had  been  asleep."  This  sensation  may  be  very  local — 
confined  to  the  toes,  fingers,  or  eyelids  ;  or  may  extend  up  the  extremities, 
almost  over  the  whole  body,  according  to  the  susceptibility  of  the  indi- 
vidual. The  remedy  must  now  be  discontinued,  or  the  dose  diminished, 
and  only  given  just  often  enough  to  keep  the  system  under  its  influence. 
This  sensation  is  to  aconite  wliat  salivation  is  to  mercury.  By  it  we  shall 
not  be  misled.  Like  salivation,  it  may  sometimes  seem  to  fail,  at  others 
the  effects  may  follow  a  single  dose,  but  on  the  whole  it  is  a  certain 
measure  of  the  patient's  tolerance  of  the  drug.  The  reader  may  easily 
produce  the  sensation  on  himself  by  taking-  a  drop  or  two  in  water  two, 
three,  or  four  times  a  day. 

The  medicine  is  useful  in  all  felirile  ailments  ;  in  nervous  excitement;  in- 
deed, whenever  the  heart's  action  is  quickened  or  the  temperature  increased. 
There  are  few  such  diseases  in  which  1  have  not  at  some  period  exhibited 
it.  I  often  make  it  serve  the  place  of  salines,  and  in  many  cases  it  is  an 
excellent  substitute  for  digitalis.  When  sufficient!}^  diluted  tincture  of 
aconite  is  tasteless — a  recommendation  of  no  small  value  to  some  people. 
For  children  a  little  syrup  makes  it  as  palatable  as  sweetmeats.  If  not 
diluted  enough,  it  produces  numbness  or  tingling  of  the  mouth  and  throat 
by  its  contact.  This  property  of  acting  locally  on  the  membrane  may 
be  utilized  for  medical  purposes.  Thus  in  tonsillitis  and  other  inflamma- 
tions in  the  fauces  and  mouth  it  ma}-  be  given  in  powders,  made  by  rub- 
bing up  the  tincture  with  a  few  grains  of  sugar.  In  1854  I  began  to 
use  it  in  the  form  of  lozenges,  a  method  I  was  employing  with  many 
other  medicines.  Of  late  years  I  have  substituted  jujubes  under  the 
name  of  pastilles  for  local  remedies  to  the  throat.  A  gargle  may  also  be 
cautiously  used,  but  should  not  be  too  strong.  Sometimes  we  may  paint 
the  faucial  membrane  with  the  tincture  diluted  with  glycerine  and  water. 
This  arrests  pain  and  often  puts  a  stop  to  the  inflammatory  process,  but  if 
carelessly  done  may  paralyze  the  soft  palate  for  hours — a  result  the  pa- 
tient is  not  likely  to  forget,  as  if  the  uvula  falls  on  the  epiglottis  it  will 
cause  a  suffocative  cough  or  a  choking  sensation  which  will  distress  and 
alarm  him. 

In  catarrh  of  the  upper  air-passages  a  few  doses  of  aconite  will  often 
be  all  the  medicine  required,  and  when  there  is  febrile  excitement  it  is 
specially  indicated.  In  acute  bronchitis,  particularly  in  the  early  stage 
and  as  long  as  pvrexia  is  present,  small  doses  may  be  administered  rather 
frequently  in  place  of  the  older   salines  and  antimonials.      Its  febrifuge 


ANTIPYKETICS.  1 S  J 

properties  are  as  marked,  its  diaphoretic  action  often  sufficient,  and  it 
seems  also  to  possess  some  expectorant  virtue,  tlie  membrane  being 
soothed  but  not  stimulated  under  its  influence.  In  chronic  bronchitis 
the  propriety  of  giving  it  will  be  determined  by  the  condition  of  the 
heart.  The  powerful  depressant  action  on  the  circulation  must  never  be 
forg-otten,  and  we  know  that  in  chronic  bronchitis  and  many  other  re- 
spiratory diseases  all  cardiac  depressants  are  not  untrequently  contra-indi- 
cated. In  capillary  bronchitis  and  catarrhal  pneumonia  aconite  may  be 
employed  as  a  febrifuge  Avith  the  same  reservation  respecting  its  action 
on  the  heart.  In  the  early  stage  it  may  often  replace  the  ordinary  saline 
or  diaphoretic  mixture  and  preclude  the  necessity  of  small  doses  of  anti- 
mony. At  the  commencement  of  acute  pneumonia  it  will  restrain  the 
febrile  excitement,  relieve  pain,  soothe  the  nervous  system,  reduce  the 
temperature,  and  promote  perspiration.  It  does  not  preclude  the  use  of 
quinine  as  an  antij^yretic  ;  indeed,  I  have  often  given  these  medicines  in 
combination  or  concurrently,  and  I  have  conducted  pneumonia  through 
its  several  stages  with  little  medicine  except  aconite  and  quinine,  and 
may  remark  that  the  employment  of  these  in  moderate  doses  is  by  no 
means  to  be  regarded  as  simple  expectancy.  In  pleurisy,  aconite  fulfils 
a  twofold  purpose,  it  reduces  the  febrile  excitement  and  assuages  the 
pain.  In  cases  of  slight  extent  and  moderate  intensity  little  other  inter- 
nal medication  is  called  for  so  long  as  the  pulse  indicates  its  use.  Of 
course,  no  one  will  suppose  that  it  can  arrest  effusion  into  the  pleura  or 
to  any  extent  promote  reabsorption.  It  is  for  its  restraining  influence 
on  the  febrile  excitement  that  in  this  and  other  diseases  it  is  to  be  em- 
ployed. In  some  cases  of  asthma  it  has  occasionally  given  relief.  In 
phthisis  it  is  useful  in  the  intercurrent  attacks  of  inflammation  and  also 
to  restrain  pyrexia.  It  is  when  the  pulse  runs  high,  and  when  there  is 
excessive  susceptibility  to  pain,  that  it  seems  to  be  most  useful.  Here, 
of  course,  it  is  only  employed  as  a  palliative  to  meet  temporary  indica- 
tions, but  as  such  it  may  prove  a  comfort  to  the  patient,  though  without 
in  any  way  influencing  the  general  progress  of  his  disease.  When  a  feb- 
rifuge is  temporarily  called  for  it  is  efficient,  and  has  the  advantage  over 
many  others  that  it  does  not  derange  digestion. 

The  tincture  of  the  root  is  the  best  preparation  for  internal  use.  It 
is  unfortunate  that  there  have  been  such  differences  in  the  strength  of 
tinctures  in  use.  Fleming's  tincture  is  too  strong  and  should  be  dis- 
carded, as  accidents  have  occurred  from  its  use.  The  London  Pharma- 
copceia  tincture  was  three  times  the  strength  of  our  British  Pharma- 
copoeia, which  is  one  in  eight.  The  tincture  of  the  United  States 
Pharmacopoeia  corresponds  with  the  former  I>ondon  Pharmacopoeia,  and 
is  therefore  three  times  the  strength  of  our  present  British  Pharmacopoeia. 
The  latter  authority  gives  the  dose  as  five  to  fifteen  minims,  but  I  have 
already  said  this  is  much,  too  high.     For  general  use  T  would  recommend 


186  THERAPEUTICS    OF    THE    RESPIRATORY   PASSAGES. 

only  one  to  three  as  safer  and  equally  efficient.  Only  occasionally  need 
five  be  given  at  a  dose.  The  United  States  Pharniacopceia  tincture  would 
be  efficient  in  from  one-fourth  of  a  minim  to  one  minim.  The  extract  is 
not  nearly  so  uniform  in  power.  The  pastilles  I  use  contain  one-half 
minim  of  tincture  in  each.  The  alkaloid,  aconitia,  is  so  powerful  when 
pure  that  it  is  only  adapted  for  external  use. 


CHAPTER    XYII. 

NEUROTICS. 

We  pass  now  to  remedies  the  chief  value  of  which  depends  on  their 
influence  over  the  nervous  system.  The  most  striking  group  of  these  is 
that  to  which  the  term  narcotics  has  been  applied.  In  its  widest  sense 
this  word  may  be  used  concerning-  anything  that  causes  sleep  or  stupor. 
It  is  perhaps  as  well  restricted  to  those  which  positively  stupefy,  and  then 
other  words  may  be  used  to  express  other  qualities  which  may  be  more 
or  less  possessed  by  narcotics.  Thus  we  have  soporifics  and  hypnotics 
which  induce  sleep  ;  sedatives  which  reduce  excitement,  and  anodynes 
which  relieve  pain.  Acro-narcotics  have  sometimes  been  grouped  sepa- 
rately, cardiac  and  vascular  sedatives  and  depresso-motors  are  terms 
which  explain  themselves,  and  sometimes  neurotics  used  to  produce  a 
particular  condition  are  named  accordingly,  as  mydriatics,  which  dilate 
the  pupils,  and  myotics,  which  contract  them,  and  many  other  groups.  A 
true  sedative  ought  not  to  produce  a  previous  stage  of  excitement,  but 
the  term  is  also  loosely  employed  with  reference  to  both  soporific  and 
anodyne  qualities. 

KARCOTICS. 

Narcotics  first  cause  excitement  and  then  stupefy,  just  as  we  have 
seen  alcohol  does,  but  the  period  of  excitement  is  shorter.  They  are, 
however,  distinctly  excitants,  that  is  during  the  early  stage  of  their  op- 
eration, and  they  are  therefore  sometimes  called  stimulants  ;  indeed,  we 
sometimes  employ  them  for  this  very  quality.  The  late  Dr.  Anstie  held 
that  the  relief  of  pain  was  due  to  this  stimulant  action,  and  that  in  neu- 
ralgia stimulant  not  narcotic  doses  would  suffice.  So  in  prostration  from 
fever  and  other  acute  diseases  the  stimulating  influence  of  small  doses 
of  opium  has  sometimes  been  sought,  and  I  think  that  the  same  effect 
may  be  obtained  from  other  narcotics.  We  use  narcotics  for  various  pur- 
poses :  first  of  all,  to  produce  sleep  or  for  their  hypnotic  quality;  then 
to  abate  pain,  for  their  anodyne  influence,  or  to  overcome  spasm,  when 
they  become  anti-spasmodics  ;  then  to  restrain  secretion  and  sometimes 
hemorrhage,  when  they  are  astringents,  or  on  the  other  hand  to  promote 


188  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

secretion,  as  in  the  case  of  some  sudorfics.  Further,  they  are  used  to  con- 
trol irritation  and  inflammation,  when  they  may  be  called  antiphlogistics  ; 
and  lastly,  as  we  have  said,  they  are  often  valuable  stimulants.  In  refer- 
ence to  respiration,  some  of  the  narcotics  greatly  retard  it,  and  they  are 
apt  to  interfere  with  expectoration  and  augment  pulmonary  congestion. 
Others,  however,  stimulate  the  respiratiory  centre,  instead  of  depressing 
it,  and  so  quicken  the  breathing.  The  effect  of  these  remedies  varies 
greatly,  according  to  the  age,  the  idiosyncrasy  and  the  habits  of  the  pa- 
tient. The  last  point  is  of  the  highest  importance,  inasmuch  as  persons 
may  so  accustom  themselves  to  the  use  of  narcotics  that  ordinary  doses 
take  no  effect. 

Opium. — Opium  is  the  type  of  narcotics,  and  by  far  the  most  impor- 
tant of  the  class  on  account  of  the  great  range  of  its  action.  It  has,  in- 
deed, often  been  regarded  as  the  most  important  of  all  medicines,  and 
spoken  of  as  "  God's  great  gift  to  man."  The  effect  of  a  single  small 
dose  is  usually  mild  excitement  together  with  a  willingness  for  quietude 
and  a  tendency  to  dose,  or  to  a  dreamy  state  of  semi-sleep,  but  with  an 
effort  tills  gives  way  to  a  readiness  to  work.  Movement  is  easy,  fatigue 
is  not  felt,  but  in  repose  drowsiness  comes  on.  The  ideas  flow  fast,  chas- 
ing each  other  in  rapid  succession,  but  are  not  so  easily  sustained.  Pain, 
if  present,  is  numbed  or  even  subdued.  Secretion  is  generally  lessened, 
except  that  of  the  skin.  Hence  there  is  dryness  of  the  mouth,  nose,  and 
fauces,  no  doubt  of  the  entire  respiratory  mucous  membrane,  though  later 
a  secretion,  but  more  viscid  than  usual,  sets  in.  Sleep,  when  obtained,  is 
often  disturbed  and  dreamy,  and  the  patient  wakes  up  unrested,  perhaps 
Avith  nausea  or  at  least  a  want  of  appetite,  and  a  disposition  to  headache 
which  sometimes  becomes  distressing. 

With  a  larger  medicinal  dose  the  excitement  is  more  marked,  but  of 
briefer  duration.  At  first  the  pulse  and  respiration  are  both  quickened,  but 
they  soon  beqpme  slower,  and  the  first  stage  gives  way  to  the  second, 
drowsiness  is  succeeded  by  sleep  more  or  less  profound,  and  on  waking 
the  uncomfortable  condition  is  often  still  more  marked.  When  a  toxic 
dose  is  taken  the  preliminary  excitement  is  scarcely  perceived,  but  the 
patient  is  plunged  rapidly  into  a  comatose  state,  and  lies  unconscious,  re- 
sembling a  person  intoxicated  by  alcohol  or  one  suffering  from  congestion 
of  the  brain.  The  respiration  is  slow,  deep,  and  stertorous,  the  pulse 
full  and  slow,  though  perhaps  strong  for  a  time — the  pupils  are  contracted  ; 
if  roused  the  patient  soon  relapses  into  his  unconscious  state.  At  this 
stage  death  does  not  often  take  place,  but  unless  relief  be  afforded,  pros- 
tration soon  comes  on,  the  coma  becomes  complete,  so  that  the  patient 
cannot  be  roused,  and  the  pupils  are  closely  contracted,  though  on  the 
approach  of  death  they  may  dilate  widely.  The  respiratory  effects  are 
feeble,  slow,  and  imperfect,  the  pauses  between  them  long,  and  at  length 
they  stop  altogether,  death  occurring  through  failure  of  respiration  ;  the 


NEUROTICS.  189 

pulse  is  no  longer  full  and  slow,  but  has  become  feeble  and  rapid,  and  it 
gets  weaker  and  quicker  ;  the  skin  is  cold  and  covered  with  clammy 
sweat  ;  the  countenance  cyanosed.  Even  yet  it  is  possible  for  the  patient 
to  be  saved,  but  recovery  will  be  gradual.  Sometimes  toxic  symptoms 
are  set  up  by  moderate  doses,  and  occasionally  after  small  medicinal  doses 
in  consequence  of  the  idiosyncrasy  of  the  individual,  serious  symptoms 
occur  ;  thus,  within  three  minutes  after  a  hypodermic  injection  of  morphia 
profound  coma  has  appeared.  In  other  cases  intense  depression  has  fol- 
lowed a  moderate  dose  ;  in  others  vomiting  takes  the  place  of  sleep 
or  follows  it,  and  very  often  severe  dull  headache  with  giddiness  and  a 
general  aggravation  of  tlie  unpleasant  symptoms  previously  mentioned 
are  produced.  When  these  symptoms  are  not  very  distressing  rest  in 
the  recumbent  posture  renders  them  bearable,  but  when  they  are  severe 
antidotes  should  be  administered.  Cases  have  been  recorded  in  which  a 
single  dose  has  produced  struggling  for  breath  or  syncope  and  even 
death.  Other  cases  have  occurred  in  which  opium  has  set  up  delirium 
or  convulsions.  A  more  frequent  source  of  anxiety  is  very  prolonged 
sleep.  A  case  has  been  communicated  to  me  in  which  after  a  hypoder- 
mic injection  of  morphia  the  patient  slept  on  soundly  for  about  thirty 
hours.     More  rarely  there  is  either  delirium  or  convulsion. 

Death  mostly  occurs  from  failure  of  respiration.  This  is  due  to  a 
direct  effect  on  the  respiratory  centre  in  the  medulla,  for  in  animals  whose 
pneumogastrics  had  been  cut  Gscheidlen  found  the  respiration  was  as 
much  affected  as  when  this  had  not  been  done.  After  death  the  bronchi 
present  a  highly  congested  appearance,  and  this  congestion  extends 
through  the  bronchial  walls,  the  inner  fibrous  coat  being  specially  af- 
fected. On  the  circulation  opium  produces  a  primary  but  transient  ac- 
celeration of  the  pulse,  which  is  followed  by  decrease  in  the  rate  with 
increase  of  its  force  and  fulness,  and  to  this  succeeds  either  a  gradual 
return  to  the  natural  condition  or  else  as  the  patient  loses  strength  the 
pulse  again  rises  in  rapidity.  The  slow  full  pulse  of  the  second  stage  of 
poisoning  appears  to  be  due  to  the  effect  upon  the  inhibitory  cardiac 
nerves,  to  which  we  may  also  ascribe  the  increase  of  the  arterial  pressure, 
for  Gscheidlen  found  that  morphia  did  not  reduce  the  pulse  after  di- 
vision of  the  vagi  and  that  if  they  were  cut  during  the  second  stage  of 
poisoning  the  operation  produced  an  extraordinary  rise  in  the  rate  of  the 
pulse.  Other  experiments  seem  to  show  that  the  peripheral  ends  of  the 
vagi  are  stimulated,  as  are  also  the  inhibitory  cerebral  centres.  The  quick, 
feeble  pulse  of  the  third  stage  seems  to  be  due  to  paralysis  of  the  pe- 
ripheral vagi,  for  at  that  stage  stimulation  of  the  peripheral  end  of  the 
divided  nerve  does  not  affect  the  heart. 

It  is  unnecessary  for  our  present  purpose  to  trace  the  physiological 
effect  of  opium  in  all  the  organs,  nor  need  we  pass  in  review  the  numer- 
ous uses  to  which  it  has  been  put  in  general  therapeutics,  but  presuming 


100  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

these  to  be  familiar  to  the  reader  we  shall  content  ourselves  with  men- 
tioning those  points  in  relation  to  the  respiratory  passages  which  we  are 
desirous  of  bringing  before  them.' 

Opium  will  often  arrest  an  ordinary  catarrh,  so  will  a  dose  of  morphia_ 
Christison  believed  that  it  would  cut  short  tonsillitis  in  the  early  stage, 
and  certainly  many  a  sore  throat  in  persons  subject  to  quinsy  has  thus 
been  arrested.  In  a  common  cold  the  coryza  is  often  stopped  by  a  single 
dose,  and  so  it  is  in  a  feverish  catarrh  or  influenza,  though  in  the  latter 
case  the  symptoms  are  apt  to  return  as  the  influence  of  the  medicine 
passes  away,  but  a  second  dose  will  again  hold  them  in  check.  If  prop- 
erly combined  with  other  remedies  this  will  hasten  recovery,  or  rather  re- 
duce the  length  of  the  attack.  There  is  another  form  of  coryza  which  is 
also  checked  and  very  often  completely  stopped  by  a  dose  of  opium  or 
morphia,  viz.,  that  produced  by  iodide  of  potassium.  Moreover,  I  have 
often  witnessed  the  immediate  relief  of  all  the  symptoms  of  iodism  by  a 
single  dose  of  morphia.  Dover's  powder  as  a  diaphoretic  is  a  favorite 
form  to  employ  in  catarrhal  cases  and  is  certainly  one  of  the  most  effi- 
cient. It  is,  however,  rather  bulky,  and  for  a  full  dose  a  single  pill  is  not 
sufficient  ;  generally  I  prefer  morphia.  Some  add  quinine  to  their  opiate, 
but  it  is  useless,  unless  a  large  dose  be  given,  and  a  few  small  doses  after 
the  narcotic  has  done  its  work  may  be  given  with  more  advantage. 

Opiates  are  often  useful  in  asthma.  In  some  cases  a  hypodermic  in- 
jection of  morphia  will  at  once  cut  short  a  most  painful  paroxysm  ;  on 
the  other  hand  there  are  cases  in  which  a  single  dose  will  bring  on  an 
attack.  In  the  paroxysms  of  dyspnoea  produced  by  emphysema  consid- 
erable circumspection  should  be  exercised  in  prescribing  opiates,  though 
they  often  afford  great  relief.  In  other  neuroses  of  the  respiratory  or- 
gans opium  may  claim  a  place.  In  pertussis  it  is  often  used,  and  Cop- 
land thought  that  tinct.  camph.  comp.  was  the  best  form  in  which  to 
prescribe  it. 

In  bronchitis  opiates  allay  irritation  and  restrain  secretion,  hence 
they  enter  into  so  many  cough  medicines.  It  is  often  taught  that  they 
are  contra-indicated  in  severe  bronchial  affections,  and  much  care  must 
certainlv  be  taken  in  prescribing  them  for  old  or  weakly  patients  when 
the  expectoration  is  copious  and  duskiness  of  the  skin  shows  that  ox- 
idation is  deficient.  In  such  a  condition  to  produce  narcosis  is  certainly 
dano-erous  ;  expectoration  accumulates  during  the  profound  sleep  and  the 
patient  may  be,  so  to  say,  drowned  in  his  own  bronchial  secretion .     Nev- 

'  In  this  chapter  the  history  is  passed  by  in  consequence  of  its  extent.  There  lies  be- 
fore me  a  list  of  upward  of  two  hundred  separate  treatises  on  opium,  to  say  nothing  of 
morphia  and  other  neurotics.  It  is  impossible  to  analyze  such  a  literature  in  the  space 
at  my  disposal,  and  therefore  scarcely  any  references  will  be  given.  It  is  hoped  that 
the  reader  will  be  satisfied  to  have  the  subject  treated  as  it  presents  itself  from  my 
own  experience. 


NEUROTICS.  191 

ertheless,  even  with  rather  free  expectoration,  with  a  violent  cough  and 
only  slight  rales  and  no  sign  of  deficient  oxidation,  opiates  may  relieve 
the  cough,  and  properly  given  they  tend  to  diminish  secretion.  To  nar- 
cotize by  a  large  dose  is  one  thing  ;  to  give  a  few  small  doses,  watching 
their  effect,  is  another  thing  ;  besides  we  can  combine  them  with  ammo- 
nium or  other  stimulants.  It  is  the  depressant  influence  on  the  respi- 
ratory centre  which  is  to  be  feared,  and  to  counteract  this  we  must 
administer  respiratory  stimulants.  The  doses,  too,  must  be  carefully  regu- 
lated if  we  would  obtain  the  benefits  of  opium  without  its  dangers.  Even 
in  old  age  and  in  infancy  it  may  be  made  to  yield  some  benefit  if  em- 
ployed with  skill  and  caution.  I  have  given  it  to  a  lady  of  eighty-four  in 
severe  bronchitis,  but  with  alternate  doses  of  ammonia,  atropia,  and 
strychnia,  and  a  friend  over  ninety  years  always  took  it  for  every  cold 
he  caught.  Hypodermic  injection  is  not  desirable  in  these  cases,  since 
the  full  effect  of  the  dose  is  produced  immediately.  What  is  wanted  is 
rather  to  obtain  the  effect  of  repeated  minute  doses,  so  as  to  stimulate 
as  well  as  to  compose,  and  the  distress  of  the  patient  needs  something 
frequently.  This  is  one  of  the  great  uses  of  ether  ;  a  few  drops  can  be 
taken  often  and  usually  relieves  the  breathing. 

It  is  sometimes  feared  to  give  opium  in  the  dry,  hacking  cough  of 
pulmonary  disease,  but  I  find  it  often  useful.  AVhen  these  distressing 
coughs  depend  on  morbid  conditions  of  the  throat,  that  part  should  be 
attended  to  ;  even  then  morphia  lozenges  may  be  useful,  but  other  more 
efficient  topical  remedies  ought  to  be  employed,  such  as  vapors,  sprays, 
paintings,  and  other  applications.  The  larynx  should  be  inspected  and 
if  necessary  laryngoscopal  medication  brought  into  play.  When  a  dia- 
phoretic is  needed  Dover's  powder  is  suitable,  but  when  the  reverse  is 
rather  required  atropia  may  be  combined  with  morphia.  This  last  combi- 
nation is  often  of  the  utmost  value,  and  by  a  variation  in  the  proportions 
we  may  accomolish  very  different  results  ;  thus  we  may  relieve  the  cough, 
perhaps  the  expectoration,  and  almost  certainly  the  perspiration  without 
at  all  depressing  the  respiratory  centre.  So,  too,  in  bronchitis  the  secre- 
tion may  be  restrained  and  with  it  the  cough  when  the  respiration  is  not 
shallow  nor  the  face  blue,  and  in  this  case  the  relief  thus  produced  may 
be  permanent. 

In  paroxysmal  dyspnoea  due  to  cardiac  disease  and  preventing  sleep 
morphia  given  hypodermically  is  often  valuable.  It  is  strongly  recom- 
mended in  such  cases  by  Dr.  Clifford  Allbutt,  who  also  employed  it  to 
assuage  the  pain  of  angina  pectoris  or  that  caused  by  intra-thoracic  tu- 
mors. Of  course  cardiac  dyspnoea  arising  from  dropsy,  etc.,  will  not  be 
relieved  by  this  treatment,  which  is  only  adapted  for  paroxysmal,  not 
permanent  dyspnoea.  It  may  be  added  that  it  need  not  be  given  every 
night,  but  once,  twice,  or  thrice  a  week,  according  to  the  urgency  of  the 
dyspnoea. 


192  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

In  chronic  plithisis  it  is  difficult  to  exaggerate  the  relief  that  may  be 
afforded  by  this  remedy  or  to  summarize  the  indications  for  its  use. 

Sometimes  the  stimulant  effect  of  opiates  is  a  disadvantage.  Graves 
tauo-ht  us  how  this  may  be  restrained  by  means  of  antimony,  and  the 
combination  he  suggested  certainly  enables  us  to  extend  the  use  of  opium, 
tliough  the  discovery  of  other  hypnotics  has  lessened  the  necessity  for 
his  combination.  Aconite  may  be  employed  with  a  view  of  preventing 
the  stimulant  action,  though  it  materially  assists  some  of  the  other  prop- 
erties. Frequently  during  a  course  of  aconite  I  administer  an  occasional 
dose  of  morphia  or  opium,  and  find  that  it  not  only  accomplishes  the  pur- 
pose for  which  it  is  given  but  renders  the  aconite  more  efficacious,  while 
the  latter  so  reacts  that  a  smaller  dose  of  the  opiate  suffices.  We  may 
also  employ  the  bromides  in  conjunction  with  opium  in  such  a  way  as  to 
modify  its  action.  Not  that  the  two  medicines  should  be  taken  together 
but  administered  at  suitable  intervals.  The  headache,  sickness,  and 
other  disagreeable  symptoms  which  are  apt  to  follow  a  full  opiate  may 
be  greatlv  restrained,  if  not  prevented,  by  bromide.  Some  persons  for 
this  purpose  give  a  full  dose  with  the  opium  ;  I  prefer  a  smaller  quantity 
— a  couple  of  moderate  doses,  preceding  the  opium,  so  that  the  patient 
may  be  under  the  influence  of  the  bromide.  When  it  is  taken  it  will 
often  prevent  or  shorten  the  stag-e  of  excitement,  a  good  night's  rest  is 
thus  secured,  and  the  subsequent  headache,  etc.,  prevented.  Should  it 
not  succeed  in  doing  this,  another  small  dose  can  then  be  taken.  The 
hvpnotic  effect  of  the  opium  is  certainly  increased  by  the  bromide. 
My  attention  was  first  drawn  to  these  reactions  of  the  remedies  on  each 
other  by  observing  the  effects  of  morphia  on  patients  who  were  taking  a 
course  of  bromide.  Chloral  liydrate  may  also  be  made  to  modify  the  ef- 
fects of  opium,  e.g.,  a  person  under  the  influence  of  opium  in  the  stage  of 
excitement  will  drop  off  to  sleep  at  once  after  a  very  small  dose  of 
chloral,  and  so  several  hours  of  repose  may  be  gained.  Very  often, 
when  persons  accustomed  to  opiates  were  known  to  be  kept  awake  by 
them  for  many  hours  together,  have  I  cut  short  tliis  dis'tressing  sleepless- 
ness by  five  to  ten  grains  of  chloral  hydrate.  The  action  of  belladonna  in 
conjunction  with  opium  is  so  important  that  it  will  be  treated  of  further 
on,  after  treating  of  belladonna. 

Children  bear  opium  very  badly,  so  do  the  very  old.  A  single  drop 
of  laudanum  has  proved  fatal  to  a  young  child  ;  it  should,  therefore,  only 
be  given  to  children  in  exceptional  cases  and  with  the  greatest  caution, 
only  in  the  liquid  form. 

Morphia  salts  are  distinguished  therapeutically  by  what  may  be 
termed  negative  properties,  as  compared  with  opium,  thus  they  are  less 
constipating,  less  sudorific,  less  stimulating.  Moreover,  they  produce 
less  discomfort  afterward.  Of  course  we  are  speaking  of  ordinary  doses, 
since  naturally,  weight  for  weight,   the  alkaloid  is  much  more  powejful 


NEUROTICS.  193 

than  the  crude  drug.  The  morphia  salts  do  constipate,  they  are  diapho- 
retic, and  a  stimulant  stage  usually  precedes  their  narcotic  action.  These 
points  may  be  observed  after  hypodermic  injections,  but  in  this  case  the 
effect  on  the  alimentary  canal  may  be  less  marked  ;  still,  generally  it  may 
be  observed.  The  neutral  tartrate  of  morphia  is  sufficiently  soluble  in 
distilled  water,  and  keeps  sufficiently  well  to  afford  us  a  non-irritating  and 
non-acid   solution   (introduced  by  Messrs.  T.  &  A.  Smith,  of  Edinburgh). 

Oodeia  seems  to  be  only  a  feeble  hypnotic,  but  it  is  sometimes  useful, 
when  morphia  disagrees,  to  allay  cough.  With  regard  to  the  other  opium 
alkaloids  the  statements  made  are  very  conflicting. 

Belladonna  and  Atropia  produce  effects  quite  contrary  to  those 
caused  by  opium  and  morphia,  nevertheless  they  are  often  used  in 
combination,  and  sometimes  are  said  to  reinforce  each  other.  So  we 
may  with  advantage  take  them  up  here.  Belladonna  has,  more  or  less, 
been  known  as  a  counter-poison  to  opium  for  some  three  centuries,  but 
special  attention  has  only  been  drawn  to  them  since  18G2,  when  Dr.  W.  J. 
Norris  wrote  his  paper  in  t\\e  American  Journal  of  the  Medical  Scie7ices. 
Dr.  Hughes  Bennett  {^Brit.  3Ied.  -T.,  1874)  experimented  carefully  with 
'atropia  and  morphia,  and  concluded  that  the  one  is  antagonistic  to 
the  other  within  a  limited  area,  since  which  time  these  conclusions  have 
been  confirmed  and  frequently  acted  upon.  Modern  experience  with  the 
alkaloid  shows  the  accuracy  of  earlier  observations  with  the  crude  drugs, 
and  atropia  is  undoubtedly  a  valuable  counter-poison  to  morphia  or  opium, 
and,  moreover,  may  be  used,  as  alread\'  stated,  to  prevent  some  of  the 
disagreeable  symptoms  produced  by  opium.  How,  then,  does  it  act  ?  By 
its  effect  on  the  respiratory  centre  of  the  medulla,  for  belladonna  stimu- 
lates this  important  point  while,  as  we  have  seen,  opium  depresses  it.  In 
this  respect,  therefore,  the  one  is  the  physiological  antagonist  of  the 
other.  It  is  often  urged  that  the  antagonism  is  not  complete,  that  in 
some  respects  the  one  reinforces  the  other.  This  may  be  admitted,  but 
does  not  alter  the  fact  that  they  largely  oppose  each  other,  and  just  as 
we  understand  more  fully  the  exact  area  of  their  antagonism,  so  much 
the  more  certainly  shall  we  be  able  to  avail  ourselves  of  this  property. 
No  one  will  now  dispute  that  animals  poisoned  by  morphia  have  been 
saved  from  death  by  the  administration  of  atropia,  and  several  patients 
have  recovered  from  accidental  opium  poisoning  under  the  f r-ee  use  of  hy- 
podermic injections  of  atropia.  We  say  the  free  use,  but  let  it  not  be 
given  recklessly,  every  dose  should  be  watched.  All  depends  on  the  res- 
piration ;  a  single  large  dose  has  been  recommended,  but  this  plan  is  not 
prudent  ;  it  is  easy  to  repeat  a  small  one  if  necessary.  It  is  true  that  a 
poisonous  dose  has  been  given  at  once  and  the  patient  has  recovered 
from  both  poisons,  but  it  would  be  safer  to  give  less  and  repeat  accord- 
ing to  the  effect  ;  we  may  thus  keep  always  on  the  safe  side.  When  the 
respiration  beg-ins  to  fail,  an  injection  of  a  fortieth  or  a  twentieth  of  a 
13 


194  THERAPEUTICS    OF   THE    KESPIRATORY    PASSAGES. 

grain  of  atropia  is  enough  ^^ro  ton.  if  the  function  responds,  if  hot  it 
can  be  repeated  in  a  quarter  of  an  hour.  So,  if  it  acts  well  but  a  relapse 
comes  on  another  dose  can  be  given.  When  the  respiration  has  fallen 
to  four,  it  may  be  doubled  at  once  by  an  injection,  which  need  not  be  re- 
peated until  the  breathing  again  grows  less  frequent,  or  unless  there  has 
been  no  improvement  for  a  long  period.  In  this  cautious  way  a  series  of 
relapses  may  be  met,  and  so  tlie  patient  tided  over  the  time  while  the 
morphia  is  being  eliminated.  Dr.  Fothergill  injected  a  grain  of  atropia 
at  once,  in  a  case  of  accidental  poisoning — this  was  certainly  not  without 
risk.  He  would  advise  generally,  of  course  after  emptying  the  stomach, 
one-fourth  or  one-third  of  a  grain  "  before  respiration  is  gravely  affected." 
He  warns  us  that  there  is  a  difference  of  susceptibility  in  patients,  which 
is  true  as  far  as  doses  of  a  seventy-fifth  to  a  twenty-fifth  are  concerned, 
but  in  massive  quantities  this  can  scarcely  count,  and  if  it  could,  a  patient 
is  quite  as  likely  to  be  unusually  susceptible  as  the  reverse.  Whenever 
we  come  to  doses  that  might  prove  fatal  or  dangerous,  difference  in  the 
degree  of  susceptibility  is  inappreciable.  It  is  rather  the  amount  of 
opium  still  in  the  system  that  accounts  for  the  tolerance  of  the  counter- 
poison.  The  cardiac  and  vaso-motor  actions  of  belladonna  are  no  doubt 
of  use  in  opium  narcosis,  but  it  is  the  respiratory  stimulus  on  which  we 
must  depend.  But  we  have  anticipated,  and  may  as  well  go  back  to  the 
general  effects  of  belladonna. 

In  moderate  doses,  dryness  of  the  mouth  and  throat  with  perhaps  some 
disorder  of  the  vision  and  dilated  pupils  may  be  produced.  A  larger 
quantity — a  physiological  dose  will  very  decidedly  disorder  the  vision 
and  perhaps  produce  diplopia,  fully  dilate  the  pupils,  and  cause  not  only 
intense  dryness  in  the  throat,  but  distinct  redness  of  the  fauces;  the  pulse 
rises  rather  rapidly  to  120  or  more,  and  sometimes  a  scarlet  flush  comes 
over  the  face  and  neck  and  may  travel  over  the  whole  body  ;  it  does  not 
present  the  punctuations  of  scarlet  fever  and  is  not  followed  by  desqua- 
mation, except  very  rarely.  It  is  sometimes  said  that  the  pulse  falls  be- 
fore the  rise,  if  so,  the  fall  must  be  very  transient  and  is  certainly  not 
generally  detectable;  the  medicine  seems  rather  to  produce  a  febrile  state 
with  very  quick  pulse,  the  beat  of  the  heart  being  felt,  and  that  un- 
pleasantly, the  temples  throbbing,  and  the  hot  dry  skin  and  dry  mouth 
and  throat  being  very  disagreeable.  Often  the  intellect  is  not  affected 
until  quite  late  even  by  poisonous  quantities,  but  confusion  and  giddi- 
ness are  common  symptoms,  as  are  extreme  restlessness  and  a  staggering 
gait.  Neither  is  drowsiness  produced,  but  rather  the  reverse,  although, 
of  course,  it  may  happen  that  a  patient  falls  asleep  because  the  poison 
has  counteracted  a  cause  of  previous  wakefulness.  Later,  delirium  comes 
on,  and  this  is  often  furious  ;  sometimes,  too,  convulsions  may  ensue  ; 
when  the  delirium  is  not  furious  it  is  always  wakeful — the  patient  sees 
visions  and  dreams  dreams,  in  which  he   is  entirely  absorbed,  so  that  his 


NEUROTICS.  195 

attention  cannot  be  drawn  to  the  things  around  him  ;  the  delirium  may 
persist  for  a  long  time,  but  in  the  end  it  subsides  into  stupor,  just  as  the 
convulsions  when  present  pass  into  paralysis.  If  these  late  symptoms 
appear  early,  it  may  generally  be  concluded  that  a  very  large  quantity 
of  the  poison  has  been  taken.  We  do  not  see  cyanosis  or  other  sign  of 
respiratory  failure  except  at  the  very  last,  then  no  doubt  the  heart  and 
respiration  both  usually  fail.  But  we  must  consider  these  and  some  other 
systems  separately. 

Circulatory  System. — On  the  heart  itself  atropia  acts  as  a  direct  de- 
pressant poison,  but  a  large  quantity  must  be  present  for  such  an  effect 
to  be  apparent.  On  the  cardiac-accelerator  centres,  or  possibly  on  the 
nerves  themselves,  it  acts  as  a  stimulant,  and  unless  in  fatal  doses  it  fails 
to  destroy  the  excitability  of  these  nerves.  The  ends  of  the  vagus  may 
be  stimulated  for  a  moment,  but  are  quickly  depressed,  the  pulse  rapidly 
rising,  and  its  rate  cannot  be  reduced  by  faradization  of  the  vagus.  The 
vaso-motor  system  is  also  stimulated  and  the  blood-pressure  raised — at 
any  rate  so  long  as  the  doses  are  not  excessive.  Very  large  quantities 
depress  the  ganglia  and  even  the  cardiac  muscle  and  the  ventricle  is 
found  in  diastole  post-mortem. 

Respiratory  System. — Belladonna  increases  the  number  and  depth  of 
the  respiration  and  this  it  does  by  directly  stimulating  the  centre  in  the 
medulla,  for  the  acceleration  takes  place  even  though  the  vagi  have  been 
previously  divided.  Loss  of  power  in  the  respiratory  nerves  may  occur 
at  the  close,  and  the  patient  may  die  from  asphyxia  ;  but  this  is  probably 
not  from  failure  of  the  centre,  though  some  have  conjectured  that  such 
failure  occurs.  It  may  be  as  well  to  mention  that  coincidentally  with 
the  stimulation  of  the  centre  there  is  perhaps  depression  of  the  bronchial 
ends  of  the  vagus,  lessening  the  tension  of  the  muscular  coat  of  the  tubes 
and  so  facilitating  the  air-current,  while  at  the  same  time  there  is  depres- 
sion of  the  afferent  branches  of  the  vagus  which  tends  to  relieve  cougli 
and  dyspnoea  by  abating  sensibility  and  reflex  action. 

Nervous  System. — Belladonna  or  its  alkaloid  is  an  excitant,  a  delir- 
iant,  but  not  a  hypnotic  ;  so,  as  to  the  brain,  it  opposes  opium.  True  it 
sometimes  is  given  to  procure  sleep,  but  it  can  only  do  so  indirectly  ; 
therefore,  though  it  has  been  called  a  narcotic,  and  though  coma  comes 
on  at  the  end  in  cases  of  poisoning,  it  scarcely  deserves  the  name.  In 
fact,  in  medicinal  doses,  it  may  be  employed  to  remove  or  prevent  the 
effects  on  the  brain  of  morphia.  By  a  careful  graduation  of  the  doses 
we  may  precisely  antagonize  the  cerebral  action  of  one  of  these  medi- 
cines by  the  other.  Dr.  Fraser's  experiments  show  that  the  action  on 
the  spinal  centre  is  stimulant,  although  at  first  there  is  paralysis,  because 
tlie  function  of  the  motor  nerves  is  suspended.  Lemattre,  Meuriot,  Be- 
zold,  and  Bloebaum  have  shown  that  in  large  doses  atropia  can  suspend 
tlie  excitability  of  the  efferent  or  motor  nerve  fibres.     Still  the  dose  re- 


IDG  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

quired  to  produce  total  suspension  is  so  large  that  it  may  cause  death 
before  excitability  is  entirely  lost.  Both  the  nerve-trunk  and  the  pe- 
ripheral intra-muscular  terminations  are  affected,  and  no  stage  of  pre- 
liminary excitement  has  ever  been  observed  to  precede  the  depression. 
This  decided  influence  over  the  spinal  nerves  is  important  vpith  regard  to 
the  therapeutical  application  of  the  remedy. 

3Iuscular  System. — The  voluntary  muscles  appear  to  be  unaffected  and 
after  death  their  contractility  is  unimpaired.  On  non-striated  muscular 
fibre  it  is  believed  to  exercise  a  paralyzing  influence,  to  which  is  often  re- 
ferred its  effect  on  the  intestine.  It  may,  however,  be  doubted  whether 
this  is  not  rather  due  to  depression  of  the  splanchnics  permitting  increased 
peristalsis,  and  to  increase  secretion.  It  is  also  believed  by  many  to  act 
directly  on  the  unstriped  muscular  fibres  surrounding  the  arterioles,  and 
perhaps  also  in  other  situations,  as,  e.g.,  in  the  bladder. 

Glandular  System. — The  secretion  of  the  salivary  and  mucous  glands 
is  arrested  in  a  most  remarkable  way  by  belladonna,  which  also  suspends 
the  secretion  of  the  skin.  As  first  shown  by  Schiff,  section  of  the  chorda 
tyinpani  arrests  the  secretion  of  the  submaxillary  gland,  after  which  gal- 
vanization of  the  peripheral  end  produces  an  increased  flow  of  saliva. 
Keuchel  found  that  when  atropia  was  administered  to  an  animal  before 
cutting  the  chorda-tympani  galvanization  of  the  peripheral  end  was  un- 
able to  excite  secretion,  thus  showing  that  the  end  of  the  nerve  was  par- 
alyzed by  the  poison.  Belladonna  checks  the  secretion  of  milk,  and  this 
property  is  occasionally  taken  advantage  of  in  therapeutics.  In  small 
doses  it  is  also  diuretic,  though  there  is  a  good  deal  of  variation  in  this 
respect.  Dr.  J.  Harley  estimated  that  the  water  of  the  urine  was  doubled 
in  amount,  and  his  experiments  indicate  an  increase  in  the  solid  constitu- 
ents, particularly  phosphates  and  sulphates.  After  poisonous  doses  the 
secretion,  though  it  may  be  increased  at  first,  soon  diminishes  and  event- 
ually may  be  suppressed.  Meuriot  found  that  the  secretion  rises  and 
falls  with  the  arterial  pressure.  Perhaps  the  diuretic  effect  of  small  doses 
may  be  produced  by  raising  the  tension  in  the  glomeruli  of  the  Malpig- 
hian  bodies. 

Temperature. — Moderate  doses  produce  a  rise,  toxic  doses  a  fall  ; 
probably  these  changes  correspond  with  the  rise  and  fall  in  the  blood- 
pressure.  No  doubt  the  increased  metabolism  tends  to  increase  the  pro- 
duction of  heat. 

Tlie  Eye. — Belladonna  produces  characteristic  effects  on  this  organ. 
Applied  locally  or  given  internally  it  dilates  the  pupil.  Locally  it  par- 
alyzes the  peripheral  ends  of  the  ocular  motor  nerves,  and  perhaps  also 
stimulates  those  of  the  sympathetic.  When  given  internally  it  is  carried 
in  the  blood  to  the  eye,  and  there  apparently  acts  in  the  same  manner  as 
if  applied  locally. 

Atropia  is  almost  entirely  eliminated  by  the  kidney.     It  passes  into 


NEUROTICS.  197 

the  urine  quickly,  and  its  effects  therefore  begin  to  decrease  early.  The 
production  of  a  rash  now  and  then  suggests  that  possibly  a  portion  may 
escape  by  the  skin,  but  we  have  no  proof  that  it  does  so.  The  urine  of 
an  atropinized  animal  dilates  the  pupil  of  another  when  applied  locally, 
and  there  is  little  doubt  that  as  a  rule  all  medicinal  doses  pass  out  in  the 
urine.  Perhaps  this  accounts  for  some  of  the  symptoms  on  the  bladder 
which  have  been  observed. 

Therapeutically  belladonna  or  atropine  has  been  employed  (a)  to  re- 
lieve pain,  (b)  to  relax  spasm,  (c)  to  stimulate  the  heart  and  respiration, 
(d)  to  arrest  secretion. 

a.  To  relieve  pain  it  is  so  vastly  inferior  to  opium  that  we  may  say 
it  is  almost  useless,  though  it  has  often  been  tried,  and  some  still  retain 
faith  in  its  asserted  anodyne  qualities.  We  are  speaking  now  of  its  in- 
ternal use.  There  is  a  good  deal  of  evidence  in  favor  of  its  local  ap- 
plication. Trousseau  administered  in  neuralgia  one-fifth  of  a  grain  every 
hour  until  giddiness  came  on,  and  then  lessened  the  dose,  but  kept  up 
the  medication  for  three  days.  Anstie,  Mr.  Ch.  Hunter,  and  Bartholow 
say  that  when  it  does  act  in  relieving  pain  the  effect  is  more  permanent 
than  that  of  morphia.  But  all  advocates  of  its  use  lament  its  uncertainty, 
which  Mr.  C  Hunter  finds  very  perplexing.  It  is  the  local  application 
that  is  efficacious  in  this  direction.  No  doubt  internally  and  hypoder- 
mically  in  large  doses  it  may  affect  the  afferent  nerves  and  so  tend  to 
assuage  pain,  while  it  may  also  modify  the  circulation  in  the  part,  and 
thus  contribute  to  the  relief  of  pain.  This  is  why  hypodermic  injections 
for  the  relief  of  pain  should  be  made  as  near  as  possible  to  the  suffering 
point.  But  after  all  opium  is  the  great  anodyne  and  belladonna  only 
exceptionally  or  indirectly  useful  for  the  purpose. 

b.  As  an  antispasmodic  belladonna  is  more  effectual,  and  this  to  some 
extent  accounts  for  the  reputation  it  acquired  as  an  anodyne.  When 
colic,  cramp,  and  other  spasmodic  affections  are  relieved,  of  course,  the 
pain  is  removed.  In  spasm  of  the  voluntary  muscles  produced  by  injury 
to  a  nerve  atropine  is  effectual  provided  it  be  injected  directly  into  the 
affected  muscle,  as  practised  by  Dr.  Weir  Mitchell ;  and  then  it  doubt- 
less acts  by  paralyzing  the  end  organs  of  the  nerves.  In  this  way,  too, 
it  may  relieve  rheumatic  spasms.  By  the  mouth  it  is  ineffectual  for 
these  purposes,  probably  because  we  cannot  administer  large  enough 
doses  to  enable  a  sufficient  amount  to  circulate  in  the  part.  In  the  in- 
voluntary muscles  it  seems  to  be  more  powerful,  but  even  here,  when 
possible,  the  local  use  is  the  most  effectual,  but  when  we  cannot  avail 
ourselves  of  this,  we  may  administer  it  by  the  mouth.  The  action  on 
non-striated  muscular  fibres  accounts  for  its  repute  in  colic,  laryn- 
gismus stridulus,  asthma,  pertussis,  some  forms  of  constipation,  spasm 
of  the  sphincter,  and,  indeed,  a  number  of  spasmodic  affections,  in 
which  it  has  been  more  or  less  successfully  employed. 


198  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

c.  As  a  respiratory  and  cardiac  stimulant,  belladonna  is  of  much 
more  importance.  In  full  therapeutical  doses  atropine  increases  the 
frequency  and  force  of  the  pulse,  raises  the  temperature,  and  otherwise 
acts  so  as  to  produce  a  febrile  condition,  while,  as  we  have  already  shown, 
it  stimulates  respiration.  It  may  be  employed  simply  as  a  cardiac  stim- 
ulus. Graves  recognized  its  value  in  typhus  fever  ;  it  has  often  been  em- 
ployed in  scarlet  fever,  erysipelas,  etc.  It  has  been  used  to  rouse  the 
heart  in  the  collapse  of  cholera.  Professor  Schafer  advises  a  dose  to  be 
administered  before  the  administration  of  chloroform  as  a  preventive  of 
cardiac  failure.  But  we  should  remember  that  later  on  large  doses  ex- 
haust the  irritability  of  the  cardiac  ganglia.  It  is,  then,  as  a  respiratory 
stimulus  that  it  is  most  valuable,  acting  directly  on  the  centre.  Its 
greatest  use  is  when  respiration  is  failing-,  as,  for  instance,  in  opium-poi- 
soning. The  stimulating  effect  on  the  respiratory  centre  may  be  com- 
pared to  that  of  ammonia,  but  we  must  remember  that  the  latter  promotes 
bronchial  secretion,  quite  an  opposite  effect  to  that  of  belladonna.  The 
two,  however,  may  often  be  given  with  advantage  at  the  same  time  ;  thus, 
in  bronchitis,  when  respiration  is  failing  and  the  pulse  feeble,  even  though 
rapid,  with  deficient  oxidation,  we  may  often  tide  over  the  danger  by 
persistently  stimulating  the  centre.  Our  predecessors  relied  on  car- 
bonate of  ammonia,  calling  it  a  stimulating  expectorant.  We  may  give  it 
just  as  they  did,  but  reinforce  it  by  a  dose  of  atropine  whenever  its 
effect  seems  insufficient.  Dr.  Fraser  found  atropine  at  once  restored  the 
respiration  in  poisoning  by  calabar  bean,  and  the  antagonism  to  opium 
in  this  respect  is  well  established.  Besides  the  stimulating  effect  on  the 
centre,  there  is  a  depressant  influence  on  the  periphery,  which  is  doubtless 
of  importance  when  the  remedy  is  used  in  I'espiratory  diseases  ;  thus 
the  depression  of  the  afferent  branches  of  the  vagus  in  the  bronchi  would 
diminish  reflex  action  as  well  as  sensibility,  and  so  tend  to  relieve 
cough  and  dyspnoea,  while  the  depression  of  the  bronchial  termini  of 
the  vagus  would  reduce  the  tension  of  the  muscular  coat  and  so  facilitate 
the  air-current. 

d.  Atropia  paralyzes  the  extreme  branches  of  the  chorda  tympani  ; 
possibly,  also,  it  acts  on  the  gland-cells  and  also  on  a  centre  for  sweat,  if 
such  a  centre  exist.  We  find  the  secretion  of  the  mammary,  sudoriparous, 
and  salivary  glands  are  all  diminished  or  suspended  under  its  influence. 
It  will  arrest  excessive  salivation  from  almost  any  cause  ;  thus  it  will  sus- 
pend mercurial  ptyalism,  and  it  will  neutralize  the  effect  of  pilocarpine. 
It  will  check  local  sweats  when  used  locally,  and  administered  by  the 
stomach  or  h3^podermically  it  will  control  general  sweats,  even  those 
produced  by  exercise  or  the  Turkish  bath.  In  the  colliquative  sweats  of 
l^hthisis,  Dr.  Costa  stated  (Phil.  3fed.  Times)  in  1871  that  a  seventy- 
fifth  of  a  grain  at  bedtime  would  prove  an  efficient  remedy,  and  his  ob- 
servation has  since  been  abundantly  confirmed. 


NEUROTICS.  199 

In  diseases  of  the  respiratory  passages  the  uses  of  belladonna  are 
numerous  and  important  ;  in  inflammation  or  congestion  of  the  mucous 
lining  attended  with  abundant  secretion  the  indication  for  its  use  is  dis- 
tinct. Whether  the  nose,  the  fauces,  the  larynx,  or  bronchi  be  affected 
chiefly,  a  few  doses  will  restore  the  normal  circulation,  and  restrain  the 
excessive  secretion.  In  influenza  or  in  catarrhal  fever  a  large  portion  of 
the  respiratory  mucous  tract  is  involved,  and  the  general  depression  is 
often  very  marked  ;  here,  then,  we  have  indications  for  the  use  of  bella- 
donna, which  it  is  to  be  feared  are  often  overlooked.  It  will  relieve  the 
intense  depression  by  restoring  the  circulation,  while  it  acts  favorably  on 
the  inflamed  membrane,  in  the  stage,  that  is,  of  secretion:  when  the  mem- 
brane is  dry  it  will  not  be  appropriate.  When  catarrh  affects  the  nose 
only,  or  the  nose  and  fauces,  or  perhaps  the  conjunctivas,  belladonna 
should  be  useful,  for  it  dries  the  Schneiderian  membrane  and  conjunctivne, 
as  well  as  the  mouth,  the  fauces,  and  tonsils.  In  laryngeal  catarrh,  it  is 
not  so  useful,  perhaps,  because  here  secretion  is  not  so  abundant,  and 
vet  in  some  cases  of  functional  aphonia  it  exercises  a  favorable  influence. 
In  a  couple  of  hours  after  a  full  dose  the  sensation  of  dryness  passes 
away  ;  a  viscid  secretion  now  appears  and  renders  the  mouth  and  throat 
clammy,  while  the  tongue  is  covered  with  a  white  fur.  If  the  secretion 
should  be  still  too  abundant,  the  dose  may  be  repeated.  It  will  be  ob- 
served that  in  these  cases,  when  not  too  severe,  a  single  dose  may  suffice, 
but  many  prefer  to  give  minute  doses,  say  a  drop  or  two  of  tinct. 
belladonnas  every  hour  until  the  patient  is  atropinized.  When  this  plan 
is  adopted  it  is  desirable  that  the  first  dose  or  two  should  be  larger  than 
the  succeeding  ones.  Here  I  would  also  remark  that  the  indications 
from  the  state  of  the  membrane  point  also  to  opium,  wliich  is  an  invalu- 
able remedy  in  these  cases,  and  may  be  advantageously  combined  with 
atropine,  which  reinforces  the  effect  on  the  membrane,  while  it  counter- 
acts the  depressing  influence  on  the  centre,  and  the  opium  in  its  turn 
frequently  prevents  the  drying  action  of  the  belladonna  on  the  skin  and 
even  secures  a  gentle  perspiration.  The  modifying  influence  of  one  drug- 
over  another  may  often  be  secured  in  this  way.  A  further  example  is 
afforded  by  aconite,  which  may  be  given  at  the  same  time  as  belladonna, 
whenever  there  is  much  feverishness  ;  the  aconite  allays  the  fever,  re- 
strains or  prevents  the  stimulating  effects  of  the  atropine  on  the  circula- 
tion, and  promotes  perspiration,  while  the  atropia  may  be  thus  compelled, 
as  it  were,  to  expend  its  energies  on  the  mucous  membrane. 

In  asthma  belladonna  relieves  both  cough  and  dyspnoea,  as  it  does 
also  the  paroxysms  of  dyspnoea  which  occur  in  emphysema,  but  for  these 
purposes  full  doses  have  to  be  given  ;  Hyde  Salter  found  this  and  gave 
ten  minims  of  tinct.  belladonnae  every  two  or  three  hours  until  a  distinct 
effect  was  produced,  and  if  the  patient  prove  insusceptible  still  larger 
doses  may  be  required,  e.g.,  half  a  drachm  as  a  single  dose  to  arrest  or 


200  THERAPEUTICS    OF   THE    KESPIRATOEY    PASSAGES. 

avert  a  paroxysm.  As  soon  as  distinct  symptoms  are  produced  the  dose 
may  be  diminished,  and  if  the  paroxysms  usually  last  long  it  is  better  to 
give  divided  doses.  When  a  full  dose  is  needed,  I  prefer  the  hypodermic 
method.  Possibly  some  of  the  larger  doses  that  have  been  required  "were 
in  consequence  of  the  tincture  not  being  good  ;  of  course  the  alkaloid  is 
more  certain,  but  a  well-prepared  tincture  is  also  efficient,  or  the  succus 
may  be  preferred.  The  remedy  is  only  useful  where  the  symptoms  indi- 
cate the  necessity  of  its  effects.  Thus  a  moist  skin,  abundant  expecto- 
ration, and  quiet  pulse  are  in  its  favor,  but  feverishness,  with  scanty  ex- 
pectoration, contra-indicate  it.  Fumigation  by  belladonna  leaves  dipped 
in  a  solution  of  nitre  and  dried,  is  sometimes  preferred  ;  these  prepared 
leaves  are  burned  in  a  close  room  and  the  patient  breathes  the  fumes. 
Trousseau  used  cigarettes  made  of  the  leaves  of  belladonna,  hyoscyamus, 
and  stramonium  moistened  with  a  solution  of  opium.  When  the  par- 
oxysms of  asthma  come  on  pretty  regularly  in  the  morning  a  dose  of 
atropia  taken  at  bedtime  will  sometimes  prevent  the  expected  attack. 

In  laryngismus,  in  pertussis,  and  in  any  neurosis  of  the  respiratory 
system,  we  may  be  glad  to  avail  ourselves  of  the  properties  of  bella- 
donna. Its  antispasmodic  effect  is  here  again  to  be  considered,  and  as 
in  asthma  full  doses  are  required,  that  is  to  say,  to  obtain  good  results, 
we  must  produce  the  physiological  effects,  though  as  soon  as  they  are 
manifested  the  dose  should  be  lessened.  Children  are  more  insusceptible 
to  the  action  than  adults,  so  that  as  much  as  ten  minims  of  the  tincture 
may  have  to  be  given  every  hour  to  a  child  of  one  or  two  years  old,  and 
even  that  may  not  dilate  the  pupil.  The  cases  in  which  it  is  most  effect- 
ual are  those  in  which  the  bronchial  secretion  is  considerable.  It  is  dis- 
favored by  some  when  bronchitis  is  present,  but  this  is  probably  because  it 
has  been  given  during  the  febrile  stage  ;  it  is  most  effectual  when  pyrexia 
has  completely  subsided,  about  the  third  week,  when  it  will  be  found  to 
exercise  considerable  influence  over  the  paroxysms.  It  is  true  that  their 
violence  should  be  abating  about  this  period,  but  with  every  allowance 
for  that  it  must  be  admitted  that  belladonna  exercises  a  favorable  influ- 
ence, and  so  it  will  at  an  earlier  date  when  the  cough  is  even  more  con- 
vulsive, provided  the  bronchial  secretion  be  free  and  the  fever  not  con- 
siderable, or  be  restrained  by  other  remedies  given  concurrently. 

In  diphtheria  belladonna  may  be  administered,  either  with  a  view  of 
supporting  the  respiration  or  of  restraining  exudation.  As  it  suspends 
secretion  in  the  fauces,  it  has  been  assumed  that  if  given  in  time  it  may 
prevent  the  formation  of  the  false  membranes.  As  diphtheria  is  an  ex- 
ceedingly depressing  disease,  it  may  be  safely  employed  in  the  hope  that 
it  may  do  this,  as  if  not,  its  influence  will  be  favorable  in  supporting  the 
circulation.  At  a  late  stage  it  may  be  used  to  stimulate  the  respiratory 
centre,  and  can  be  given  hypodermically  when  ammonia  cannot  be  taken. 
In  the  night  sweats  of  phthisis  atropia  is  almost  certain  to  maintain 


NEUROTICS.  201 

its  reputation.  It  seldom  fails  to  arrest  this  distressing  symptom,  and 
the  dose  required  for  this  purpose  is  usually  so  small  that  no  inconven- 
ience is  to  be  apprehended.  Moreover,  it  does  not  require  to  be  long 
continued.  One  small  dose  at  bedtime  will  often  suspend  the  sweats 
for  several  nights.  Sometimes  it  requires  to  be  given  for  two  or  three 
nights  in  succession,  and  then  no  more  may  be  needed  for  some  time. 
The  y-|"„  grain  will  often  suffice,  sometimes  even  less,  but  at  others  -^j  or 
-g^y  may  be  required. 

Belladonna  with  Opium. — We  have  seen  that  in  some  instances 
opium  and  belladonna  neutralize  each  other,  as  also  do  their  alkaloids, 
morphia  and  atropia.  These  opposing  actions  are  so  important  that  it 
is  desirable  to  consider  them  further.  We  may  utilize  the  two  remedies 
at  the  same  time,  giving  them  in  combination  or  alternately  with  each 
other,  especially  in  painfnl  neuroses.  Opium  will  cut  short  asthma  or 
catarrh  ;  so  will  belladonna.  Opium  produces  certain  unpleasant  symp- 
toms, belladonna  prevents  most  of  these.  From  an  early  period  the  op- 
posite effects  upon  the  pupil  could  not  be  overlooked.  Morphia  and 
atropia  are  often  combined  in  hypodermic  injections  ;  these  same  alka- 
loids may  also  be  administered  by  the  mouth.  Morphia  produces  less 
disagreeable  effects  than  opium,  and  we  may  further  reduce  the  unpleas- 
ant action  by  adding  atropine.  When  we  only  want  the  good  effect 
of  opium  or  morphia,  we  can  often  neutralize  the  evil  consequences  by 
the  addition  of  a  suitable  dose  of  atropia.  The  antagonism  between  the 
two  agents  is  not  universal,  that  is,  does  not  cover  the  whole  field  of 
action,  but  the  area  over  which  it  exists  is  exceedingly  favorable  for  our 
therapeutical  efforts.  In  some  points  there  is  no  antagonism  ;  for  in- 
stance, atropia  does  not  prevent  the  relief  of  pain  by  opium  ;  indeed, 
many  have  supposed  that  it  rather  assists  the  anodyne  action.  Erlen- 
meyer  says  that  the  antagonism  is  complete  in  regard  to  the  action  on 
the  brain,  so  that  when  the  two  remedies  are  given  together  no  coma  re- 
sults ;  but  on  the  sensory  nerves  there  is  no  antagonism,  and  accord- 
ingly he  combines  them  for  the  relief  of  pain.  Bartholow  holds  that  the 
anodyne  effect  of  opium  is  even  assisted  by  atropia.  On  the  other  hand, 
the  existence  of  the  antagonism  has  been  denied  by  Brown-Sequard  and 
Dr.  John  Harley.  The  latter  has  criticised  the  recorded  cases  of  opium 
poisoning  which  have  been  treated  by  atropia  with  considerable  ingenu- 
ity, but  has  scarcely  succeeded  in  reversing  the  general  judgment.  The 
Edinburgh  committee  presided  over  by  Dr.  Hughes  Bennett  reported 
that  :  (1)  sulphate  of  atropia  is  within  a  limited  range  physiologically 
antagonistic  to  meconate  of  morphia  ;  (2)  meconate  of  morphia  does  not 
act  antidotally  after  a  large  dose  of  atropia,  thus,  while  atropia  is  an 
antidote  to  morphia,  morphia  is  not  an  antidote  to  atropia  ;  (3)  meconate 
of  morphia  does  not  antagonize  the  effect  of  atropia  on  the  branches 
of  the  vagi  supplying  the  heart.     From   this  it  may  be  concluded  that 


202  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

atropia  is  of  more  value  to  correct  the  action  of  morphia  than  the  reverse, 
and  this  coincides  witli  our  clinical  experience  ;  but  there  are  cases  in 
which  morphia  may  with  advantage  be  made  the  corrective  of  a  full 
medicinal  dose  of  atropia. 

Therapeutically  the  question  of  dose  is  of  most  importance,  and  it 
varies  with  reg-ard  to  each  remedy  in  different  individuals  ;  considerable 
experience  is  therefore  required  to  obtain  the  best  results.  If  one-fif- 
tieth grain  of  atropia  will  stop  certain  effects  of  a  quarter  grain  of  mor- 
phia it  is  by  no  means  certain  that  one-hundredth  grain  will  serve  to 
correct  one-eighth.  Indeed  the  presumption  might  rather  be  the  other 
way.  Both  alkaloids  affect  the  brain,  but  differently  ;  it  has  been  said 
that  when  they  are  combined  the  sleep  is  longer,  and  some  assert  that 
atropia  prevents  the  insomnia  of  morphia,  that  is,  shortens  the  stage  of 
excitement.  My  experience  is  rather  the  reverse  of  this,  which  certainly 
might  be  anticipated  from  the  physiological  effect  of  atropia,  which  it- 
self produces  excitement,  and  so,  a  prio)'i,  might  be  expected  to  increase 
the  excitement  of  opium.  It  is  possible  that  the  atropia  may  tend  to 
prolong  the  sleep  induced  by  morphia,  but  it  is  very  difficult  to  judge. 
It  may  reinforce  the  anodyne  property,  but  in  the  small  dose  required 
the  amount  which  could  obtain  local  access  to  the  painful  part  must  be 
infinitely  small,  and  we  have  seen  that  any  anodyne  quality  depends  on 
this  local  access.  Morphia  is  our  sure  anodyne,  and  we  only  add  the 
atropia  to  enable  the  patient  to  tolerate  it,  or  to  prevent  the  inconven- 
iences to  which  it  may  give  rise.  Nausea,  vomiting,  headache,  constipa- 
tion, syncope,  all  the  ^in  of  disagreeable  symptoms  which  so  often 
follow  the  opiate  may  be  prevented  by  a  properly  graduated  quantity  of 
atropia  added  to  the  morphia,  and  this  whether  taken  by  the  stomach  or 
injected  under  the  skin.  It  is  said  that  the  illusions  produced  by  bella- 
donna are  prevented  by  opium  and  the  sleep  is  more  rational,  but  we 
hardly  give  doses  of  atropia  which  produce  illusions.  Morphia  depresses, 
atropia  stimulates  the  heart.  A  very  minute  amount  of  atropia  will  pre- 
vent morphia  from  contracting  the  pupil.  Morphia  lessens,  atropia  aug- 
ments the  secretion  of  the  kidneys  ;  on  the  skin  the  action  is  just  the 
reverse,  morphia  promoting,  atropia  arresting  perspiration  ;  both  reme- 
dies arrest  the  secretion  along  the  respiratory  tract  ;  morphia  retards, 
atropia  increases  peristaltic  movements,  and  the  same  may  be  said  of 
their  action  on  the  intestinal  secretion.  Above  all,  opiates  depress,  but 
belladonna  stimulates  the  respiratory  centre.  It  will  now  be  seen  how 
often  the  one  may  be  made  to  supplement  the  other,  and  that  their  coun- 
ter-influences are  of  special  value  in  respiratory  diseases,  particularly 
catarrhal  affections  and  neuroses. 

As  an  average  it  takes  from  -^-^  to  j^  of  a  grain  of  atropia  to  neutral- 
ize the  effect  of  a  quarter  grain  of  morphia,  but  much  less  doses  may 
suffice  to  secure  the  freedom  from  inconvenience  which  is  desired.     Bar- 


NEUROTICS.  203 

tholow  recommends  -j-|-^  or  ^^^  grain  of  atropia  to  a  quarter  and  half  a 
grain  of  morphia.  I  have  usually  found  a  larger  proportion  of  atropia 
necessary.  In  giving  atropia  by  the  mouth,  the  dose  being  so  small  and 
the  drug  powerful,  it  seems  best  to  give  it  in  liquid  form,  the  liquor 
atropiie  sulphatis  affords  a  convenient  dose  of  one  to  two  minims  {j^  to 
g^ij),  and  this  combines  well  with  liquor  morphije.  Sometimes  it  is  desira- 
ble to  administer  aconite  at  the  same  time,  for  the  sake  of  its  febrifuge 
property  and  to  restrain  the  action  of  the  atropia  on  the  heart. 

Other  Antagonisms. — Medicines  may  be  partially  antidotal  or  antag- 
onistic, that  is  they  may  counteract  each  other  in  some  respects  but  not 
in  others,  and  we  may  call  them  antagonistic,  well  knowing  that  the  area 
over  which  they  thus  act  is  limited.  Still  their  counteraction  is  extremely 
interesting  and  important,  and  may  even  suggest  to  us  how  medicines 
may  antagonize  diseases.  It  seems  idle  to  deny  the  antagonism  because 
it  is  not  complete  ;  should  we  not  relieve  some  of  the  effects  of  a  poison, 
even  although  others  might  be  beyond  our  control? 

Atropia  and  Physostigrna. — Kleinvachter  and  Bourneville  recorded 
cases  in  which  they  observed  an  antagonism  between  these  drugs.  Bar- 
tholow  received  the  prize  of  the  American  Medical  Association  for  an 
essay  on  the  subject  in  18G8,  and  the  following  year  Dr.  Fraser  brought 
before  the  Edinburgh  Royal  Society  some  account  of  his  researches,  in 
which  he  has  shown  the  area  over  which  this  antagonism  exists.  He 
showed  that  atropia  averted  the  effects  of  a  lethal  dose  and  therefore  is 
the  antidote  for  calabar-bean.  From  one-fiftieth  to  one-thirtieth  grain 
should  be  injected  under  the  skin,  and  repeated  at  intervals  until  the 
pupils  dilate  and  the  bronchial  secretion  is  checked.  This  leads  us  to 
observe  that  calabar-bean  immensely  increases  the  secretion  of  the  lach- 
rymal, salivary,  bronchial,  and  intestinal  glands,  while  atropia  controls 
these  effects  and  establishes  its  own,  just  as  it  counteracts  the  contract- 
ion of  the  pupils  and  dilates  them.  Some  other  opposite  effects  have 
been  demonstrated  chiefly  by  Dr.  Fraser,  thus  "  physostigma  increases  the 
excitability  of  the  vagi  nerves,  while  atropia  diminishes  or  suspends  this 
excitability  ;  physostigma  diminishes  the  arterial  blood-pressure,  while 
atropia  increases  it."  It  is  remarkable  that  a  minute  dose  of  atropia 
which  is  insufficient  to  produce  an  appreciable  effect  will  suffice  to  avert 
many  of  the  effects  of  physostigma.  Although  atropia  ma}-  prevent 
death  from  calabar-bean,  the  converse  of  this  fact  has  not  yet  been  dem- 
onstrated. The  committee  of  the  British  Medical  Association  reports  that 
sulphate  of  atropia  antagonizes  to  a  slight  extent  the  fatal  action  of  calabar- 
bean,  but  that  the  area  is  more  limited  than  indicated  by  Dr.  Fraser. 

Atropia  and  Pilocarpine. — Jaborandi  excites  perspiration  and  sali- 
vation. Applied  to  the  eye  it  contracts  the  pupil,  it  retards  the  heart 
and  afterward  arrests  it  in  diastole.  These  effects  are  the  opposite  of 
those  of  atropia,  which  is  able  to  control  them  so  that  a  hypodermic  in- 


204  TUERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

jection  of  oiie-liiuidredth  of  a  grain  will  at  once  check  the  action  of   a 
dose  of  jaborandi  or  pilocarpine. 

Atropia  and  Bromal. — In  reference  to  the  bronchial  membrane  it  is 
interesting  to  observe  that  these  two  oppose  each  other.  Bromal  kills 
by  producing  extreme  excess  of  the  bronchial  and  salivary  secretions,  by 
which  the  animal  is  choked  ;  atropia  arrests  th  esesecretioiis,  and  so  far 
is  antidotal,  but  of  course  bromal  is  no  antidote  to  atropia,  as  this  latter 
does  not  destroy  life  by  its  action  on  these  glands. 

Atrojjuiand 2Iuscarin. — Schmiedeberg  showed  the  antagonism  of  these 
substances  on  the  heart.  Dr.  Lauder  Brunton  has  enlai-ged  this  area  by 
showing  that  the  dyspnosa  caused  by  muscarin  appears  to  be  due  to  power- 
ful contraction  of  the  pulmonar}"-  vessels,  blanching  the  lungs.  The  right 
heart  is  distended  owing  to  the  condition  of  the  pulmonary  vessels.  Now 
atropia  at  once  removes  the  spasm  of  the  vessels  and  sets  the  loaded  right 
heart  free,  thus  completely  removing  the  dyspnoea.  Muscarin  also  stimu- 
lates the  termini  of  the  chorda  tympani  and  so  salivates,  it  also  excites  per- 
spiration, in  both  these  respects  being  opposed  by  atropia.  It  appears, 
however,  to  dilate  the  pupil,  though  in  most  other  respects  it  antagonizes 
atropia.  Muscarin  seems  to  act  on  the  heart  by  stimulating  the  intracardiac 
inhibitory  apparatus,  much  in  the  same  wa}'  as  pilocarpine  probably  acts. 

Atropia  and  Prussic  Acid. — Preyer  says  that  atropia  paralyzes  the 
peripheral  branches  of  tlie  vagus  and  in  this  way  prevents  hydrocyanic 
acid  from  arresting  the  contractions  of  the  heart.  If  so,  it  would  be  an 
antidote  to  that  poison,  which,  however,  produces  death  so  rapidly  that 
there  is  seldom  time  for  treatment  of  any  kind. 

Atropia  and  Aconite. — Atropia  given  with  aconite,  or  a  little  before 
it,  antagonizes  the  action  on  the  heart,  but  when  delayed  for  about  a 
quarter  of  an  hour  after  a  lethal  dose  is  unable  to  prevent  death.  As 
before  remarked,  we  rnay  avail  ourselves  of  this  antagonism  when  employ- 
ing therapeutical  doses;  thus  it  often  happens  that  the  general  effects  of 
aconite  ai-e  most  desirable  and  may  be  obtained  by  its  regular  adminis- 
tration every  few  hours,  while  an  occasional  dose  of  atropia  may  be  ad- 
visable for  the  sake  of  its  effects  on  the  mucous  membrane.  On  the  other 
hand,  when  regular  doses  of  atropia  are  required,  it  may  be  desirable  to 
counteract  some  of  its  effects  by  aconite. 

Some  of  these  antagonisms  are  not  easy  to  understand  and  show  that 
the  action  is  more  complex  than  has  been  supposed.  It  is  not  a  single 
effect  which  expresses  the  properties  of  a  medicine,  although  its  thera- 
peutical value  may  depend  on  that  one.  Atropia,  as  we  have  seen,  an- 
tagonizes the  effect  on  the  heart  of  pilocarpine,  muscarin,  and  aconite, 
though  both  poison  and  counter-poison  seem  to  paralyze  the  excito-motor 
and  muscular  substance.  Further,  pilocarpine  antagonizes  the  effect  on 
the  heart  of  muscarin,  and  yet  both  seem  to  act  in  precisely  the  same 
manner.      Moreover,  atropia,  which  we   have   seen   antagonizes  so  many 


NEUROTICS.  205 

poisons,  does  not  prevent  the  effect  of  digitalis  nor  of  veratria  on  the 
frog's  heart.  Though  digitalin  antagonizes  niuscarin,  pilocarpine,  aco- 
nite, and  atropia,  Dr.  Ringer  has  suggested  "  that  these  antagonisms 
iriav  be  due  to  chemical  displacements." 

Before  leaving'  this  subject  it  may  be  remarked  that  some  other  an- 
tagonisms are  of  special  interest,  and  progress  is  being  made  in  their 
study.  Caffeine  and  morphia  are  distinctly  antagonistic,  and  guaranine 
modifies  the  action  of  morphia,  but  not  very  markedly.  Calabar-bean,  as 
we  have  seen,  provokes  the  bronchial  secretion,  and  its  action  is  greatly 
modified  by  chloral  hydrate,  which  in  some  cases  has  prevented  death 
after  a  lethal  dose,  but  it  must  be  given  before  the  full  action  of  the  phy- 
sostigma  is  produced.  The  chloral  depresses  the  respiration  and  para- 
lyzes the  centre,  as  well  as  the  circulation,  in  which  it  appears  rather 
likely  to  reinforce  the  effect  of  the  calabar-bean,  for  that  certainly  de- 
presses the  respiratory  centre.  Physostigma  has  also  been  given  in 
strychnia  poisoning,  as  well  as  in  tetanus,  but  has  scarcely  answered  the 
expectations  formed  of  it,  and  the  same  may  be  said  as  to  its  antidotal 
power  toward  atropia  and  chloral  ;  in  fact,  the  chief  use  at  present  of 
calabar-bean  or  its  alkaloid,  eserin,  is  for  local  use  in  diseases  of  the  eye. 
Strychnia  prevents  some  of  the  effects  of  aconite,  but  the  reverse  does 
not  seem  to  hold  good,  strychnia  is  also  to  some  extent  counteracted  by 
the  bromides  and  by  chloral  hydrate,  which  have  been  employed  with 
some  success  as  antidotes.  It  is  obvious  that  the  more  completely  we 
understand  the  mode  of  action  of  any  of  these  powerful  remedies,  the 
more  likely  we  are  to  be  able  to  influence  that  action  whether  by  count- 
eracting or  preventing  it,  or  by  increasing  or  reinforcing  it,  or  otherwise 
modifying  it.  A  knowledge,  too,  of  the  area  of  the  antagonisms  between 
them  helps  us  in  arranging  suitable  combinations  ;  thus,  though  a  simple 
prescription  may  often  be  best  and  it  is  certainly  desirable  to  cultivate 
simplicity  in  prescribing,  it  very  often  occurs  that  great  benefit  may  be 
obtained  by  suitable  additions  to  the  chief  remedy. 

Further,  we  may  modify  the  action  of  our  remedies  by  giving  others 
before,  with,  or  after  them,  we  may  administer  variously  acting  agents 
alternately  between  each  other.  To  modify  opium  we  g"ive  with  it 
belladonna  ;  to  stimulate  the  respiratory  centre  we  give  belladonna, 
or  atropia  alone,  and  we  may  reinforce  its  action  by  alternating 
it  with  ammonia  or  ether  ;  and  furthermore,  while  pushing  these 
remedies  we  may  obtain  the  effect  of  morphia  on  the  mucous  membrane 
by  a  small  dose  at  bedtime,  its  depressant  effect  on  the  centre  being  neu- 
tralized by  the  other  medicines.  These  delicate  alkaloids  are  easily  de- 
stroyed, caustic  alkalies  decompose  them,  even  lime-water  destroys 
atropia  so  much  that  Dr.  J.  Harley  proposed  it  as  an  antidote  in  bella- 
donna poisoning.  It  is  usually  better  to  give  these  powerful  alkaloids  in 
a   fluid   form    unless   great  reliance   can   be   placed   on  the  preparation. 


206  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

Atropia  in  combination  with  morphia  is  often  given  as  a  pill.  Atropia 
alone  lias  the  disadvantage  that  a  solution  does  not  keep  well,  and  should 
therefore  be  freshly  prepared.  The  gelatine  disks,  however,  prepared  by 
Savory  &  Moore,  keep  perfectly  ;  they  are  always  ready  for  hypoder- 
mic injection,  and  are  equally  available  for  administration  by  the  stomach, 
as  a  disk  can  be  washed  down  with  a  little  water  without  tasting. 

Hyoscyami'S  and  Stramonium. — These  two  remedies  may  be  re- 
garded as  allies  of  belladonna,  in  fact,  daturia  and  hj'oscyamia  were  for 
some  time  regarded  as  identical  with  atropia,  but  some  differences  have 
been  established,  and  other  very  similar  alkaloids  have  been  obtained 
from  the  solanacea.  The  alkaloids  have  been  used  for  subcutaneous  in- 
jection as  anodynes,  but  are  not  superior  to  atropia,  and  very  inferior  to 
morphia.  Hyoscyamine  has  also  been  employed  for  the  secondary  seda- 
tive effect  on  the  cerebrum  in  maniacal  excitement.  The  herbs  hyoscya- 
mus  and  stramonium  seem  both  to  be  more  decidedly  hypnotic  than 
belladonna,  and  hyoscyamus  has  a  special  repute  as  an  anodyne,  and  its 
secondary  or  soothing  effect  comes  on  earlier  and  is  more  marked  ;  hence, 
perhaps,  its  reputation  for  producing  sleep  and  relieving  pain.  Moreover, 
hyoscyamus  seems  to  exercise  a  special  influence  on  the  mucous  mem- 
branes. Thus  the  respiratory,  the  gastric  and  the  intestinal  lining  are 
all  soothed  by  it,  as  is  also  that  of  the  bladder.  In  these  cases  it  has 
also  been  given  with  alkalies,  and  even  with  liquor  potassse,  but  it  has 
been  shown  that  this  decomposes  it.  Its  somewhat  laxative  and  ano- 
dyne influence  on  the  bowels  makes  it  a  valuable  adjuvant  to  aperients. 

All  the  preparations  of  stramonium  have  obtained  considerable  repute 
as  antispasmodics  in  asthma,  and  their  use  has  been  extended  to  cases  of 
laryngeal  cough.  A  favorite  method  of  employing  stramonium  is  by 
fumigation  or  inhalation.  A  popular  plan  is  to  smoke  it  like  tobacco,  and 
smokers  mix  tobacco  with  it  ;  this,  however,  is  not  to  be  recommended,  as 
it  is  desirable  to  draw  the  fumes  of  the  stramonium  into  the  bronchi, 
where  its  local  action  is  believed  to  be  considerable  in  relaxing  spasm, 
and  so  relieving  the  dyspnoea,  whereas  the  fumes  of  tobacco  irritate 
rather  than  soothe.  Twenty  grains  of  the  dried  leaves  or  ten  of  tlie 
powdered  root  may  be  smoked  at  a  time,  the  fumes  being  inhaled,  or  any 
other  convenient  method  of  inhaling  the  fumes  may  be  employed.  It 
will  be  seen  that  it  is  in  pure  nervous  asthma  that  it  is  indicated  ;  in  the 
dyspnoea  of  heart  disease,  or  that  caused  by  structural  changes  in  the 
lungs,  it  is  useless.  Sometimes  it  fails  in  asthma,  but  in  other  cases  it  is 
very  successful,  the  cause  of  this  difference  not  having  been  ascertained. 
Stramonium  seems  to  be  more  directly  depressant  to  the  nerves  of  the 
bronchi  than  belladonna,  and  thus,  perhaps,  may  be  considered  as  to 
some  extent  a  respiratory  sedative,  especially  as  regards  its  local  action.' 
Given  internally,  the  extract  is  more  powerful  and  the  dose  accordingly 
smaller.       Datura  tatula,  an  allied  plant  of  more  robust  growth  belong- 


NEUROTICS.  207 

ing  to  the  stramonium  genus,  has  been  introduced  of  late  years,  as  a  sub- 
stitute for  the  older  remedy,  and  as  often  succeeding  when  that  fails  ;  it 
may  be  used  in  the  form  of  cigars,  cigarettes,  fumigations,  etc.,  in  the 
same  manner  as  stramonium.  An  extract  and  tincture  are  also  made. 
Daturia  extracted  from  it  is  more  powerful  than  atropia,  from  which 
its  salts  differ  somewhat  in  solubility  and  in  crj'stalline  form.  The  dose  is 
yicr  ^°  e'o  ^^  ^  grain,  but  it  should  be  employed  with  great  caution  ;  the 
five-thousandth  of  a  grain  applied  locally  affects  the  pupils. 

Camphor. — Camphor  excites  the  cerebrum  and  produces  a  kind  of 
intoxication,  evidently  exercising  a  considerable  influence  on  the  nervous 
system.  It  is  eliminated  by  the  skin  and  the  bronchial  mucous  mem- 
brane. It  is,  therefore,  natural  to  employ  it  in  respiratory  diseases,  in 
which,  indeed,  it  has  long  enjoyed  a  popular  reputation.  In  acute 
catarrh,  inhaled  or  used  as  a  snuff,  it  is  a  popular  remedy,  and  in  Jiay 
fever  as  much  may  be  said.  Some  authorities  have  recommended  it  in 
whooping-cough  and  other  spasmodic  affections,  others  look  upon  it 
rather  as  a  stimulant  or  perhaps  expectorant,  giving  it  in  combination  with 
ammooia  in  chronic  bronchitis,  capillary  bronchitis,  and  in  emphysema. 
Its  action  in  respiratory  diseases  seems  to  be  not  dissimilar  to  that  of 
turpentine,  to  which  it  presents  other  analogies  ;  for  instance,  it  is  anti- 
septic, antispasmodic,  etc.  The  late  Dr.  Copland  attributed  to  it  spe- 
cial value  in  bronchitis  and  asthma  ;  he  combined  it  with  ammonia  as  an 
appropriate  stimulant  when  expectoration  was  arrested  from  want  of 
power  ;  when  expectorants  were  admissible  he  often  added  it  to  them,  as 
he  did  to  diuretics,  opium,  and  other  remedies.  He  declared  that  "  in 
nearly  all  stages  of  bronchitis,  camphor  is  a  most  valuable  medicine,"  and 
added,  "  its  virtues  have  been  singlarly  overlooked  by  the  writers  on  this 
disease,"  and  further  pointed  out  that  when  exhaustion  and  difficulty  of 
expectoration  become  urgent,  "  it  is  one  of  the  most  valuable  remedies  we 
possess."  But  in  spite  of  this  opinion  of  a  most  able  observer,  the 
remedy  has  not  been  extensively  used  for  these  purposes,  except  by  a 
small  number  of  physicians,  who  have  satisfied  themselves  of  its  value. 
Though  camphor  has  been  in  tolerably  common  use  for  some  two  hundred 
and  fifty  years,  during  which  it  has  given  rise  to  a  very  considerable  lit- 
erature, and  been  recommended  for  all  sorts  of  diseases,  from  a  common 
cold  to  cholera,  its  exact  medicinal  value  has  scarcely  yet  been  fully  as- 
certained, and  it  is  perhaps  most  frequently  employed,  rather  as  an  ad- 
juvant than  for  other  purposes.  As  an  antispasmodic  it  is  not  unfre- 
quently  combined  with  musk  and  other  powerful  nervines. 

Camphor  forms  some  very  curious  compounds  with  chloral,  thymol, 
phenol,  etc.,  most  of  which  possess  distinctly  anodyne  properties.  Cam- 
phor-monobromide  is  sedative  and  antispasmodic,  as  well  as  hypnotic, 
and  from  Bouneville's  researches  appears  also  to  depress  the  circulation 
and  lower  temperature. 


CHAPTER  XYIII. 

PNEUMATICS. 

This  term  (TrvevfiaTLKd,  from  ttvcw,  I  breathe)  was  employed  by  Pereira 
to  signify  therapeutical  agents  which  acted  by  their  influence  over  respi- 
ration and  calorification.  He  included  those  which  affected  the  respira- 
tory muscles,  the  mucous  membrane,  the  breathing,  and  the  calorific  func- 
tion. In  reference  to  the  muscles,  something  has  already  been  said  in 
tlie  chapter  on  Neurotics  ;  thus  the  efficacy  of  stramonium  and  other  medi- 
cines in  relieving  spasm  of  the  bronchial  muscular  fibres  has  been  pointed 
out,  and  it  may  be  stated  that  other  medicines  possess  similar  or  opposite 
properties.  As  to  those  medicines  which  Pereira  considered  diminished 
want  of  breath,  and  which  he  termed  "  torporifics,"  these  also  are  for  the 
most  part  neurotics.  Some  of  them  have  been  supposed  to  produce  a 
condition  analogous  to  the  physiological  states  of  hibernation,  ordinary 
sleep,  asphyxia,  or  syncope,  but  most  of  them  may  be  classed  as  narcot- 
ics, and  several  are  distinct  depressants  of  the  respiratory  centre.  So 
again,  substances  >yhich  influence  animal  heat  have  been  considered 
ajnongst  refrigerants  and  antipyretics  on  the  one  hand  and  stimulants  and 
neurotics  on  the  other  ;  the  calefacients  of  Pereira  being  in  reality  excit- 
ants or  respiratory  stimulants,  i.e.,  accelerators  of  circulation  and  respira- 
tion. This  leaves  us  only  those  substances  which  act  on  the  mucous 
membrane  and  an  immense  number  of  which  are  commonly  spoken  of  as 
expectorants.  It  will,  however,  be  necessary  to  extend  our  view  beyond 
this,  and  we  must  therefore  rearrange  our  pneumatics. 

If  whatever  affects  the  respiratory  system  directly  or  indirectly  were 
to  be  included  among  pneumatics  the  word  might  as  well  have  been  em- 
ployed as  the  title  to  this  volume,  since  it  only  professedly  includes  re- 
spiratory therapeutics.  Many,  perhaps,  would  object  as  it  is  to  some  of 
the  agents  we  have  included,  but  surely  those  which  only  indirectly  af- 
fect the  respiration  ought  not  to  be  overlooked  as  remedies  for  disorders 
of  that  function,  while  other  functions  are  so  closely  related  to  it  as  con- 
stantly to  claim  attention.  Nutrition,  therefore,  and  everything  affecting 
it  are  of  equal  importance  in  diseases  of  the  respiratory  and  other  systems, 
while  in  consequence  of  the  intimate  association  between  respiration  and 
circulation  derangement  of  the  one  almost  invariably  produces  disorder 


PNEUxMATICS.  209 

of  the  other.  We  may,  then,  employ  the  word  pneumatics  for  all  those 
substances  which  influence  directly  or  indirectly  the  respiratory  system  ; 
or  rather,  we  apply  it  to  these  substances  whenever  they  are  used  for 
this  purpose,  since  almost  all  of  them  possess  other  properties  for  which 
they  may  be  even  more  frequently  employed.  Some  of  these  pneumatics 
have  consequently  been  considered  elsewhere,  and  it  will  not  be  essential 
to  repeat  what  has  been  said  concerning  them,  it  being  a  matter  of  con- 
.  venience  to  consider  the  various  actions  of  a  remedy  in  connection  with 
each  other.  Plenty  of  remedies  enter  into  more  than  one  group  in  every 
classification,  and  so  in  this  ;  our  pneumatics,  therefore,  will  include  those 
which  act  more  or  less  directly  on  some  portion  of  the  respiratory  organs 
or  influence  distinctly  their  function. 

Regarding  respiration  as  a  provision  for  interchange  between  the  at- 
mosphere and  the  blood,  we  find  that  the  function  may  be  greatly  affected 
by  changes  in  the  quality  of  the  air.  Thus  variations  in  its  temperature 
and  in  the  amount  of  moisture  it  contains  affect  every  portion  of  the 
membrane  over  which  it  passes  in  its  passage  toward  the  blood,  and  may 
even  affect  the  pulmonary  cells  and  the  circulating  fluid  itself.  So  well 
known  is  the  effect  of  unusual  cold  that  catarrh  is  continually  ascribed 
to  it,  but  dampness  is  equally  injurious,  and  the  two  combined  are  still 
more  likely  to  give  rise  to  affections  of  the  respiratory  tract.  So  disease 
of  any  portion  of  the  mucous  membrane  extending  from  the  lips  and  nose 
to  the  extreme  ramifications  of  the  air-passages,  and  even  catarrhal 
jmeumonia  may  be  produced  by  cold  and  damp.  The  opposite  condition 
of  warmth  and  moisture  is  soothing  and  sorhetimes  Ave  endeavor  to 
maintain  it  by  regulating  the  atmosphere  of  the  room  or  by  providing  a 
warm  stream  of  air  through  inhalers  or  respirators. 

Variations  in  the  pressure  of  the  atmosphere  also  exercise  consider- 
able influence.  As  previously  stated,  the  diminished  pressure  on  lofty 
mountains  increases  the  frequency  and  depth  of  the  respirations  as  well 
as  the  vascularity  of  the  lung,  and  thus  accounts  for  the  tendency  to 
hemoptysis  observed  under  such  circumstances.  In  descending  mines 
an  opposite  condition  obtains,  and  sometimes  we  may  produce  a  some- 
what similar  influence  by  causing  the  patient  to  breathe  compressed  air. 

Deficiency  in  the  quantity  of  air  available  for  respiration  may  also 
take  place,  or  the  supply  may  be  interrupted  for  a  brief  period,  or  it  may 
be  replaced  by  a  respirable  gas  like  nitrous  oxide.  Increase  of  the  sup- 
ply may  be  produced  by  resorting  to  pressure,  or  an  excessive  proportion 
of  oxygen  may  be  provided.  Then,  again,  the  amount  of  air  at  the  dis- 
posal of  a  patient  remaining  the  same,  more  or  less  may  be  actually  used 
according  to  the  activity  of  the  respiration,  and  this  we  may  sometimes 
vary  by  regulation  of  his  exercise  and  rest.  So  in  disease,  when  one  por- 
tion of  the  lung  is  rendered  useless  we  see  the  remainder  working  harder 
in  order  to  make  up  for  the  deficiency  thus  occasioned. 
14 


-10  TnELlAPEUTICS    OF    THE    RESPIIIATORY    PASSAGES. 

The  chemical  quality  of  tlie  air  may  be  altered.  This  may  occur 
from  defect  of  oxyg-en  as  well  as  from  the  presence  of  impurities.  Some- 
times tlie  attempt  has  been  made  to  increase  tlie  amount  of  oxygen,  but 
without  much  success  ;  at  other  times  inhalations  of  oxyg-en,  or  of  this 
o-as  mixed  in  various  proportions  with  air  for  short  periods  at  a  time  have 
been  prescribed.  A  resort  to  mountain  air,  or  to  the  seaside,  or  an  ocean 
voyao-e  is  a  more  usual  method  of  improving  the  quality  of  the  air 
breathed.  The  variations  in  the  air,  which  we  have  already  noticed,  go 
far  to  make  up  the  complex  influence  of  climate.  But  this  subject,  im- 
portant as  it  is  in  reference  to  respiratory  therapeutics,  is  too  extensive 
to  be  included  in  the  present  chapter  and  will  therefore  be  postponed. 

The  circumstances  relating  to  the  blood  and  general  circulation  have 
already  been  consideredj  but  we  must  not  quite  pass  over  the  vascular 
supply  of  tlie  bronchi  and  lungs.  The  circulation  through  the  bronchial 
vessels  may  be  stimulated  or  depressed  by  agents  which  act  upon  the 
general  circulation,  as  well  as  by  remedies  which  possess  a  topical  action, 
thus  exercise,  evacuants,  some  respiratory  stimulants  and  expectorants 
may  notably  stimulate  the  bronchial  circulation,  while  depressants  and 
some  Other  remedies  produce  an  opposite  effect.  So  the  pulmonary  cir- 
culation may  be  modified  by  the  systemic,  and  therefore  whatever  acts  on 
the  latter  affects  the  former  ;  besides  which  a  direct  influence  on  the  less- 
er circulation  may  be  produced  by  these  agents.  Muscarin  appears  to 
possess  a  very  direct  action,  powerfully  contracting  the  pulmonary*  ves- 
sels. 

The  muscular  system  must  not  be  overlooked.  The  muscles  of  respi- 
ration, as  we  have  seen,  may  be  affected  by  various  agencies  within  our 
control  ;  but  it  is  the  muscular  coat  of  the  bronchi  and  perhaps  also  the 
diaphragm  wjiich  we  most  frequently  seek  to  affect  by  medicines.  Inas- 
much as  spasm  of  the  bronchial  fibres  gives  rise  to  most  distressing  symp- 
toms, substances  which  control  this  condition,  whether  acting  directly  or 
indirectly,  are  sometimes  grouped  together  as  antispasmodics.  Many  of 
these  are  depressants  of  the  respiratory  nervous  apparatus  ;  others,  acting 
perhaps  through  the  same  channels,  are  grouped  as  narcotics.  Sometimes 
expectorants  become  antispasmodics  by  relieving  the  vessels  and  there- 
by causing  a  free  flow  into  the  tubes,  when  after  the  secretion  is  coughed 
up  the  spasm  suVjsides.  In  the  same  way  the  removal  of  mucus  by 
emetics  produces  subsidence  of  the  spasm,  and  the  act  of  vomiting,  as  is 
well  known,  greatly  relaxes  muscular  fibres. 

With  regard  to  the  nervous  system,  we  have  already  considered 
several  stimulants  and  sedatives  of  the  respiratory  and  cardiac  centres, 
and  we  may  add  that  other  agents  of  tliis  kind  are  within  our  grasp. 
Of  these,  ammonia  and  str3'^chnia  are  important  as  stimulants,  while  chlo- 
ral, the  bromides,  conium,  etc.,  may  be  added  to  the  depressants  we  have 
had  occasion  to  describe.     Afferent  sensory  nerves  from  all  parts  convey 


p:s"eumatics.  211 

impulses  to  the  medulla  and  produce  impressions  on  the  centre  which  in- 
fluence reflexly  the  respiratory  movements.  But  impulses  from  the  re- 
spiratory organs  themselves  are  more  important,  inasmuch  as  they  are  di- 
rect. Now  the  entire  surface  of  the  air-passages  is  abundantly  supplied 
by  the  vagi,  which  are  the  special  afferent  respiratory  nerves,  B}^  them 
impressions  are  constantly  being  collected  and  conveyed  to  the  centre, 
and  when  such  impressions  are  unusually  powerful  they  may  overflow,  so 
to  say,  and  thus  affect  other  centres.  They  may  even  reach  the  convolu- 
tions, when  they  will  be  perceived  as  sensations  referred  more  or  less 
distinctly  to  the  respiratory  organs.  We  may  thus  have  undefined,  un- 
easy sensations,  or  a  degree  of  irritation,  or  oppression  and  distress, 
or,  again,  distinct  pain.  Further,  motor  filaments  of  the  vagi  rise  in  the 
centre  and  are  distributed  to  the  bronchial  muscles  and  so  regulate  their 
contraction,  thus  controlling  the  calibre  of  the  tubes.  In  this  way  the 
bronchi  are  completely  under  the  control  of  the  medulla,  and  moreover 
the  very  impulses  which  originate  in  the  air-passages  conveyed  to  the 
centre  react  through  it  on  tlie  passages  themselves.  Now  the  afferent 
respiratory  nerves  may  be  stimulated  on  the  one  hand,  as,  e.g.,  bv  cold 
air,  irritating  gases,  or  certain  medicines  which  determine  to  the  respira- 
tory tract.  On  the  other  hand,  they  may  be  depressed,  as  by  warmth  and 
moisture  as  well  as  by  remedies  acting  more  or  less  directly  upon  them, 
and  some  of  which  deserve  to  be  called  respiratory  anodynes,  from  the 
soothing  influence  which  they  exercise  and  the  manner  in  which  thev  re- 
strain uneasy  sensations  and  relieve  pain. 

Indirect  influences  traiismitted  through  other  nerves  also  readilv  affect 
the  respiratory  centre,  and  may  therefore  be  employed  to  act  upon  it. 
Everyone  knows  how  readily  it  is  stimulated  through  the  fifth  bv  irritat- 
ing the  nostrils,  or  by  the  sudden  application  of  cold  to  the  forehead. 
In  the  same  way  it  may  be  influenced  through  the  olfactory,  optic,  and 
auditory  nerves  by  strong  odors,  intense  light,  and  loud  sounds,  as  it 
also  may  through  the  cutaneous  nerves,  as  from  counter-irritants.  On 
the  other  hand,  sedative  influences  may  be  transmitted  from  the  surface, 
as  in  warm  baths,  general  or  local,  fomentations,  poultices,  and  anodyne 
local  applications.  We  have  now  to  add  that  efferent  nervous  impulses 
may  be  also  more  or  less  modified  by  our  remedies,  e.g.,  strychnia  stimu- 
lates the  spinal  centres  of  tlie  respiratory  muscles  as  well  as  the  periph- 
eral nerves,  perhaps  both  directly  and  indirectly,  and  electricity  may  be 
called  in  as  an  immediate  stimulant.  On  the  other  hand,  opium  seems  to 
be  a  depressant  of  the  entire  efferent  tract,  while  calabar-bean  depresses 
the  spinal  centres  and  conium  expends  its  energy  chiefly  on  the  motor 
nerves. 

The  glandular  system  of  the  respiratory  tract  is  also  within  the  reach 
of  our  remedies,  and  that  not  only  as  a  whole  but  in  some  of  its  parts. 
So  that  the  secretion  from  the  nose,  throat,  larynx,  trachea,  and  bronchi 


212  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

mav  be  changed  in  quantity  or  quality,  and  this  alteration  may  affect  a 
small  portion  or  the  whole  of  the  membrane.  The  glands  may  be  stimu- 
lated bv  ammonia,  sulphur,  iodine,  most  of  the  expectorants,  and  by  some 
remedies  which  perhaps  act  topically,  being  excreted  through  the  mem- 
brane. Their  action  may  be  restrained  by  belladonna,  opium,  and  per- 
haps astringents.  Cold  and  heat,  warmth  and  moisture,  or  other  local 
remedies  also  influence  the  secretion  directly,  while  other  remedies  act 
upon  it  either  through  the  circulation  or  the  nervous  system,  some  of 
these  being  irritating,  others  soothing. 

We  are  now  prepared  to  consider  the  various  effects  produced  upon 
the  air-passages  by  the  remedies  at  our  command.  It  will  be  observed 
that  their  action  is  often  very  complex,  though  sometimes  it  is  simple 
and  perhaps  direct.  So  many  substances  and  of  such  opposite  qualities 
have  been  supposed  to  act  upon  the  secretion,  or  to  affect  its  production 
that  no  little  confusion  has  been  introduced.  Excess  of  secretion  is  so 
obvious  a  symptom  that  it  must  have  attracted  attention  from  the  earli- 
est times.  Many  substances  were  believed  to  be  capable  of  increasing  it, 
but  only  a  few  were  supposed  to  possess  the  power  of  restraining  it,  and 
accordingly  medicines  of  most  opposite  qualities  have  been  grouped  to- 
gether as  expectorants.  If  the  origin  of  the  word  {ex  pectore)  justified 
the  usage,  we  might  perhaps  apply  it  to  whatever  affects  the  sputa,  or 
that  which  is  brought  np  from  the  chest,  though  originally  it  was  no 
doubt  intended  for  whatever  increased  the  secretion.  Such  increase 
might,  however,  only  be  apparent,  the  removal  of  a  larger  quantity  not 
necessarily  implying  greater  activity  of  production.  Like  other  func- 
tions, that  of  the  respiratory  membrane  may  be  increased,  decreased,  or 
altered.  No  doubt  it  is  most  frequently  increased,  and  as  this  constitutes 
the  most  obvious  and  the  most  frequent  symptom  of  disease,  agents  which 
could  promote  it  seem  to  have  received  the  most  attention.  It  is  per- 
haps due  to  the  notion  which  so  unfortunately  prevailed  for  a  long  time, 
as  to  the  value  of  evacuants,  that  this  idea  of  promoting  secretion  was 
allowed  to  put  into  the  shade  the  equally  important  subject  of  the  possi- 
bility of  restraining  it.  Still,  it  is  curious  that  those  who  could  see  the 
desirability  of  restraining  mucous  diarrhcea  should  consider  that  an  an- 
alogous discharge  from  the  respiratory  tract  should  be  promoted  rather 
than  restrained.  It  was,  perhaps,  a  happy  thing  that  some  so-called  ex- 
pectorants really  acted  by  diminishing  and  altering  the  sputa,  rather  than 
by  stimulating  its  production.  Here,  perhaps,  it  is  but  fair  to  admit  that 
some  early  writers  '  were  conscious  of  the  evils  that  might  arise  from  the 
indiscriminate  use  of  expectorants. 


'  Ludolf,  J.  :  De  iisu  et  abusu  medicamentonim  Expectorantium.     1723. 
Buechner,  A.  E. :  De  incongruo  Expectorantium  iisu  frequent!  morborum  pectora- 
lium  causa.     1756. 


PNEUMATICS.  213 

Here  we  may  pause  to  refei-  to  certain  remedies  which  act  locally  on 
small  portions  of  the  aerian  inembranes.  These  are  first  of  all  errhines 
(from  eV,  in,  ptV,  nose),  which  are  introduced  into  the  nostrils  for  tlie  pur- 
pose of  increasing  the  nasal  discharge.  Many  of  them  are  taken  as 
snuffs  ;  some  act  merely  mechanically,  but  others  are  distinct  irritants  to 
the  mucous  membrane.  Various  acrid  powders  have  been  used  for  this 
purpose,  but  liquids  and  vapors  may  be  also  employed.  It  will  be  ob- 
served that  all  are  stimulants  to  tlie  secretion  and  we  have  no  name  for 
substances  possessing  opposite  qualities.  But  we  perhaps  oftener  use 
such  as  tend  to  restrain  secretion,  and  which  possess  emollient,  soothing, 
or  astringent  properties.  Some  internal  remedies  promote  the  nasal  se- 
cretion, but  are  not  called  errhines,  as  they  are  not  applied  locally.  Other 
internal  medicines  restrain  this  secretion.  Absorption  readily  takes  place 
from  the  healthy  pituitary  membrane.  Sternutatories  {sternutatoria,  from 
sternuo,  I  sneeze),  or  ptarmics  as  they  are  also  called  (from  Trratpw,  I  sneeze), 
also  stimulate  this  membrane,  but  these  terms  are  employed  for  medicines 
which  are  applied  locally  in  order  to  produce  sneezing  but  not  to  bring 
on  a  discharge,  though  it  is  obvious  that  such  a  stimulant  will  tempo- 
rarily increase  both  the  nasal  mucus  and  the  tears.  Cough  medicines, 
sometimes  called  bechics  ((3rjxtKd,  from  (3i^i,  a  cough),  are  not  used  to  stimu- 
late, but  rather  to  soothe  the  throat  and  larynx  :  they  comprise  a  num- 
ber of  emollients  and  demulcents  supposed  to  act  locally  during  the  act 
of  swallowing  and  to  sheathe  the  surface  from  irritants.  Various  forms 
of  linctus,  lozenges,  and  similar  remedies  are  given  with  this  intention, 
and  sometimes  small  quantities  of  expectorants  or  narcotics  are  added,  to 
which  is  due,  perhaps,  the  most  important  part  of  the  effect.  Direct  local 
applications  can  be  made  to  the  larynx  by  means  of  the  laryngoscope, 
information  concerning  which  will  be  found  in  the  author's  "  Laryngos- 
copy." Passing  further  down  the  respiratory  tree  we  come  to  medicines 
acting  upon  the  lower  portion  of  the  membrane,  and  first  of  all 

Expectorants. 

In  a  wide  sense  this  term  is  frequently  applied  to  whatever  facilitates 
the  evacuation  of  the  bronchial  secretion,  as  well  as  to  whatever  increases 
its  flow,  and  this  whether  directly  or  indirectly.  It  will  be  observed  that 
there  is  a  great  difference  in  these  two  actions.  In  each  case  more 
phlegm  is  raised,  but  in  the  one  that  is  only  because  the  removal  is 
effected  of  that  which  is  already  there,  while  in  the  other  case  there  is 
the  additional  outpouring  of  fresh  secretion.  Now  the  natural  method 
of  evacuating  bronchial  mucus  is  by  coughing,  so  that  whatever  excites 
this  action  assists  the  process.  An  irritating  gas  or  any  other  local 
stimulant  to  the  respiratory  membrane  may  thus  be  said  to  be  expecto- 
rant.    In  health,  although  moisture  is  continually  exhaling  from  the  pul- 


214  THERAPEUTICS    OF    THE    RESPIKATOKY    PASSAGES. 

monaiy  surface,  very  little  is  condensed  into  liquid  and  retained  in  the 
passages  ;  only  enough  to  maintain  the  moisture  of  the  membrane,  and 
in  combination  with  the  products  of  the  gland  to  form  a  sufficiently  tena- 
cious secretion  to  cover  the  surface  and  entangle  such  particles  as  may 
be  inspired  and  thus  enable  them  to  be  coughed  up.  Small  pellets  or 
larger  glutinous  masses  are  thus  frequently  brought  up  by  persons  who 
have  been  exposed  to  dust,  etc.  In  perfect  health  a  resident  in  a  pure 
atmosphere,  i.e.,  in  a  good  climate,  might  perhaps  scarcely  ever  cough 
up  such  masses,  but  in  towns  it  is  not  uncommon  for  these  pellets  to  be 
extruded  nearly  every  morning,  and  in  densely  populated  cities  like  Lon- 
don and  Manchester,  where  much  coal  is  burnt,  the  sooty  particles  taken 
in  give  rise  to  a  black  phlegm,  which  is  coughed  up  more  or  less  regu- 
larly. When  the  membrane  has  become  relaxed,  perhaps  from  the  re- 
currence of  catarrh,  a  secretion  of  this  kind  may  become  habitual.  In 
disease  the  cough  may  be  weak  and  insufficient  to  accomplish  the  in- 
creased labor,  and  it  may  then  happen  that  it  is  desirable  to  excite  the 
muscular  action  by  appropriate  stimuli,  or  it  may  be  necessary  to  act 
upon  the  membrane  and  the  muscles  engaged  indirectly  through  the  ner- 
vous system  ;  stimulants  of  the  respiratory  centre  may  be  called  for. 
But  in  other  cases  it  may  be  possible  to  so  sustain  and  strengthen  the 
system  as  to  give  the  patient  more  power  to  cough  ;  nutrients  and  ton- 
ics may  perhaps  do  this. 

But  a  cough  may  be  incessant  and  yet  ineffectual,  and  in  such  cases 
it  may  be  necessary  to  employ  remedies  to  restrain  it.  These  act  on  the 
mucous  membrane  or  on  the  nervous  system,  and  periiaps  on  the  pro- 
cess of  secretion.  The  irritability  of  the  pulmonary  surface  needs  to  be 
soothed  while  the  vagi  are  controlled,  and  it  may  be  that  depressants  of 
the  centre  are  also  required.  When  there  is  no  secretion  to  be  raised,  it 
may  even  be  desirable  to  employ  such  expectorants  as  provoke  the  secer- 
nent action,  concurrently  with  sedatives.  When  the  troublesome  but 
useless  cough  is  kept  up  by  disease  at  some  small  point  in  the  larynx, 
that  must  be  treated  by  local  applications,  not  by  expectorants,  which  are 
equally  useless  in  the  cough  caused  by  elongated  uvula. 

Other  hindrances  may  occur  to  the  evacuation  of  bronchial  secretion, 
the  tubes  may  be  in  a  state  of  spasm,  preventing  the  removal  and  interfer- 
ing with  the  respiration.  When  the  accumulation  is  considerable  and  the 
spasm  intense  an  emetic  will  sometimes  relieve  the  distress.  The  act  of 
vomiting  produces  relaxation  of  the  muscular  system  and  at  the  same  time 
greatly  aids  mechanically  in  clearing  the  tubes.  In  other  cases  antispas- 
modics will  bring  about  the  relaxation  of  the  bronchial  muscles.  De- 
pressants of  the  nervous  system  also  do  this,  whether  of  the  centre  or 
periphery.  Narcotics  are  sometimes  employed  for  this  purpose,  but  in 
full  doses  are  not  without  danger. 

We  may  next  direct  our  attention  to  the  accumulated  secretion.     We 


PNEUMATICS.  215 

may  act  upon  this  with  a  view  to  vary  its  quality  or  quantity.  As  to  its 
consistency,  when,  as  often  happens,  it  is  thick  and  tenacious,  and  there- 
fore difficult  to  raise,  we  may  endeavor  to  liquefy  it  in  order  to  make  it 
easier  to  g'et  up,  i.e.,  we  may  try  to  dilute  it.  This  we  may  do  iirst  of 
all  bv  inhalations  of  steam,  which  may  also  be  laden  with  other  vapors 
or  by  atomized  liquids  containing  chemical  substances  in  solution,  such  as 
certain  salines  which  are  believed  to  assist  in  attenuating  the  sputa.  But 
we  should  not  forget  that  these  vapors  and  sprays  act  upon  the  mucous 
membrane  as  well  as  its  secretions,  and  absorption  may  even  take  place. 
We  may  also  act  upon  the  secretion  through  the  system,  by  the  internal 
administration  of  medicines.  Iodide  of  potassium  is  a  powerful  atten- 
uant,  which  also  increases  the  quantity  of  the  secretion,  as  does,  perhaps, 
chloride  of  ammonium,  but  it  is  not  unlikely  that  they  do  not  merely  di- 
lute it  but  distinctly  alter  its  character.  Alkalies  used  to  be  considered 
as  liquefying  the  sputa,  but  recent  experiments  throw  some  doubt  on 
their  action.  Of  course,  whatever  increases  the  quantity  of  the  secretion 
tends  to  attenuate  it.  Another  group  of  remedies  which  facilitate  ex- 
pectoration may  produce  an  opposite  effect,  thickening'  the  secretion. 
When  there  is  a  large  quantity  of  thin,  watery  mucus  it  may  be  more 
difficult  to  raise  than  if  it  possessed  more  tenaciousness.  In  such  cases 
whatever  thickens  it  in  a  moderate  degree  may  expedite  its  exit.  Pure, 
dry  air,  even  if  cold,  will  do  this,  and  a  dry  climate  may  be  most  desirable. 
Certain  vapors  and  sprays  may  also  be  employed  to  act  on  the  membrane 
and  internally  the  administration  of  astringents  or  of  opium  may  accom- 
plish the  end.  Of  course,  whatever  checks  the  act  of  secretion  tends  to 
thicken  the  sputa.  Other  changes  in  quality  may  also  be  brought  about. 
Essential  oils  and  other  substances  which  impart  their  odor  to  the  breath 
alter  the  secretion.  Some  not  only  add  their  own  odor  but  deodorize  the 
sputa,  are,  in  fact,  disinfectant  or  antiseptic  expectorants,  and  they  are  the 
more  entitled  to  the  name,  inasmuch  as  most  of  them  stimulate  excretion. 
We  come  now  to  those  expectorants  which  affect  the  quantity  of 
sputa  secreted.  These  also  are  of  two  kinds,  those  which  stimulate  the 
secernent  function  and  those  which  restrain  it.  The  first  are  sometimes 
classed  with  eliminants,  and,  indeed,  have  been  employed  with  an  idea  of 
relieving  the  system  by  increasing  the  discharge.  Such  a  notion  is,  how- 
ever, obsolete  ;  they  may  act  by  directly  irritating  the  mucous  membrane, 
as  when  ammonia  and  other  stimulants  are  inhaled.  Others  are  intro- 
duced through  the  system,  and  being  brought  to  the  pulmonary  surface 
may  act  upon  the  vessels  there,  causing  them  to  unload  themselves  ;  or 
they  may  stimulate  the  glands  to  increased  action  ;  or,  again,  they  may 
stimulate  the  nerves  ;  or,  once  more,  circulating  in  the  blood  may  directly 
influence  the  centre.  Many  of  these  true  expectorants  are  unquestion- 
ably eliminated  through  the  respii'atory  mucous  membrane,  and  it  is 
natural  to  seek  there  the  explanation  of  their  action.     Many  of  them  are 


21G  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

very  volatile,  and  it  would  appear  that  this  quality  facilitates  their  ex- 
cretion through  the  aerian  membrane.  It  is,  indeed,  a  general  rule  that 
the  more  volatile  a  substance  the  more  easily  it  escapes  from  the  lungs. 
The  respiratory  membrane  is  in  truth  especially  adapted  for  the  inter- 
change between  the  air  and  gaseous  substances  of  the  blood,  so  that  we 
mio-ht  anticipate  that  volatile  substances  would  here  find  a  natural  out- 
let, and  this,  in  fact,  they  do.  When  they  are  present  in  too  great  a 
quantity  to  escape  l)y  this  route  the  excess  not  unfrequently  passes  off 
by  the  skin,  this  being  also  adapted  for  the  removal  of  vaporous  sub- 
stances which' may  be  compared  with  the  insensible  perspiration.  It  is 
true  that  some  medicines  of  this  kind  seem  to  be  attracted  to  the  lungs 
almost  exclusively,  while  others  are  determined  toward  the  skin  ;  but 
often  the  one  appears  to  supplement  the  other,  though  in  other  cases 
there  is  rather  a  determination  toward  other  mucous  membranes  than 
toward  the  cutaneous  surface.  We  have  said  that  these  volatile  sub- 
stances are  excreted  through  the  lungs,  and  there  exercise  their  influence 
where  they  not  only  affect  the  quantity  but  alter  the  quality  of  the  se- 
cretion, and  may,  perhaps,  replace  the  deteriorated  phlegm  by  a  more 
healthy  flow,  thus  being,  as  is  sometimes  said,  alterative.  Some  have 
doubted  whether  the  effect  is  produced  in  consequence  of  elimination 
through  the  bronchial  membrane  or  glands.  In  '•  Neligan's  Medicines," 
edited  by  Macnamara,  this  question  is  raised,  and  it  is  said  that  it  is 
perhaps  only  the  odorous  principle  which  escapes  through  this  channel. 
To  this  it  may  be  replied,  very  likely,  but  in  such  case  it  is  perhaps  this 
very  principle  to  which  the  medicinal  virtues  belong.  Further,  the  elim- 
ination by  this  channel,  not  only  of  volatile  but  of  other  expectorants, 
has  at  length  been  ascertained  by  experiment. 

Remedies  which  diminish  the  quantity  of  the  secretion  are  directly 
antagonistic  to  the  true  expectorant  which  we  have  just  considered,  but 
some  of  the  former  have  often  been  grouped  with  the  latter.  When  the 
expectoration  is  very  profuse,  its  evacuation  may  be  rendered  easier  by 
restraining  secretion,  and  so  we  have  remedies  which  might  be  termed 
"  paradoxical  expectorants,"  if  we  admit  them  to  be  expectorants  at  all. 
When  they  diminish  the  quantity  they  mostly  render  the  phlegm  thicker 
and  more  tenacious.  They  may  act  directly  on  the  mucous  membrane  or 
its  glands  ;  others  act  only  through  the  nervous  system,  either  on  the 
periphery,  as  some  neurotics,  or  on  the  centre,  as  narcotics  ;  others  con- 
tract the  vessels  as  astringents  ;  and  it  may  happen  that  some  first  of 
all  stimulate  the  vessels  to  pour  out  an  increased  quantity  of  liquid,  by 
which  they  are  relieved,  and  afterward  on  their  contracting  the  second- 
ary effect  is  produced.  Finally,  it  is  not  impossible  that  some  may  act 
indirectly  by  altering  the  quality  of  the  blood,  for  in  recent  experiments 
a  solution  of  soda  injected  into  the  circulation  was  followed  by  arrest  of 
bronchial  secretion. 


PNEUMATICS.  217 

Here  it  may  be  convenient  to  consider  the  most  recent  researches 
into  the  phenomena  of  the  secretion  of  mucus  and  the  clianges  which 
may  be  effected  by  medicines.  Professor  Rossbach  reported  {Berl.  klin. 
JVoch.),  in  1882,  the  results  of  a  series  of  experiments,  mostly  on  cats, 
which  have  since  been  confirmed  by  Petronne  [Lo  Sperimentale,  1883). 
The  method  of  procedure  was  to  open  the  trachea  and  watch  the  ap- 
pearance of  the  mucus  which  in  the  normal  state  covers  the  membrane. 
This  they  found  was  only  a  thin  layer,  which  persisted  even  when  large 
quantities  of  air  passed  over  it.  When  the  mucus  was  gently  removed 
with  blotting-paper  the  layer  reformed  within  a  minute  or  two,  but  the 
collection  was  never  so  great  as  to  run  into  drops  or  to  flow  down.  From 
this  it  would  appear  that  the  secretion  is  not  continually  going  on,  but 
that  whenever  it  is  reduced  in  quantity  by  evaporation  a  fresh  outflow 
is  produced  to  compensate  for  the  loss.  It  is  probable  that  the  consti- 
tution of  the  mucus  is  not  uniform,  but  that  the  portion  last  exuded  is 
more  watery  and  alkaline  and  therefore  adapted  to  hold  the  mucin  in 
solution.  According  to  Rossbach's  experiments  no  nervous  current,  or 
only  a  feeble  one,  is  transmitted  from  the  centre  to  the  glands  of  the  air- 
passages,  for  the  secretion  continues  in  its  usual  manner  after  section  of 
the  laryngo-tracheal  nerves.  But  vaso-motor  fibres  seem  to  reach  the 
laryngeal  lining,  as  the  secretion  appears  to  have  some  connection  with 
the  vascularity  of  the  membrane. 

Rossbach  next  observed  the  effects  of  temperature,  by  applying  hot 
poultices  and  ice-bags  to  the  animal's  body.  Within  half  a  minute  of 
the  application  of  ice  the  whole  mucous  surface  of  the  larynx  and 
trachea  was  blanched  from  the  complete  contraction  of  the  blood-vessels, 
but  in  from  one  to  two  minutes  this  passed  away  and  was  succeeded  by  a 
bluish  red  tinge,  while  such  quantities  of  mucus  were  secreted  as  to 
freely  flow  down.  On  the  removal  of  the  ice  and  replacing  the  poultice 
the  color  instantly  changed  to  deep  red.  Fresh  applications  of  ice  again 
set  up  vascular  spasm,  but  more  slowly  and  to  a  lesser  degree.  These 
phenomena  Rossbach  considered  direct  reflexes. 

Equally  interesting  results  followed  the  application  of  medicinal  sub- 
stances. No  effect  was  observed  from  a  weak  solution  of  carbonate  of 
soda  when  inhaled,  but  the  application  of  weak  ammonia  or  vinegar,  by 
painting  the  membrane,  caused  intense  hyperaemia  and  increased  secretion. 
Astringents  applied  in  the  same  way  produced  an  opacity  of  the  epithe- 
lium, so  that  deeper  changes  could  not  be  observed,  together  with  com- 
plete arrest  of  the  secretion.  Air  saturated  with  turpentine  blown  upon 
the  membrane  caused  gradual  diminution,  and  finally  arrest  of  the  secre- 
tion, which,  however,  returned  when  the  irritant  was  removed.  A 
watery  solution  of  turpentine  increased  the  secretion,  but  at  the  same 
time  diminished  the  vascularity  of  the  membrane.  From  this  it  would 
appear  that  turpentine  is  a  true  expectorant,  though  at  the  same  time  it 


218  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

removes  congestion  and  would  account  for  the  value  which  has  been 
placed  upon  it  by  some  clinical  observers.  Other  true  expectorants,  so 
far  as  these  experiments  go,  are  emetia,  apomorphia,  and  pilocarpine  ; 
but  neither  of  these  affected  the  vascularity  of  the  membrane.  It  will 
be  observed  that  clinical  experience  confirms  these  results,  especially  as 
regards  emetia  ;  pilocarpine  is  not  well  adapted  as  an  expectorant  on  ac- 
count of  its  effect  on  the  salivary  glands,  nor  unless  a  powerful  sudorific 
should  be  at  the  same  time  desired,  but  apomorphia  is  easily  tolerated 
and  does  not  often  disturb  the  appetite  or  cause  nausea,  points  which 
my  clinical  experience  confirm. 

The  antagonists  of  these  expectorants,  atropia  and  its  allies,  were  also 
shown  to  produce  the  effects  which  had  been  ascertained  by  observation  ; 
thus,  the  membrane  could  be  completely  dried  by  the  application  of 
atropia,  but  at  the  same  time  the  vascularity  was  increased.  In  the 
same  way  morphia  diminishes  but  does  not  arrest  the  bronchial  secretion 
as  atropia  does.  The  combinations  of  morphia  and  atropia  recommended 
in  our  chapter  on  Neurotics  are  thus  shown  bj'  experiment  to  possess 
the  qualities  there  stated,  and,  as  we  have  said,  these  experiments  have 
been  repeated  with  similar  results. 

Petronne  agrees  with  Rossbach  that  aniigmia  of  the  membrane  and 
atony  of  the  glands  is  brought  about  by  the  effect  of  soda  on  the  vaso- 
motor and  secretory  nerves,  when  that  alkali  is  injected  into  the  blood, 
but  a  considerable  quantity  of  the  carbonate  had  to  be  emj^loyed.  An 
experiment  of  this  kind  is  certainly  not  so  satisfactory  as  the  others  we 
have  named,  it  seems  to  show,  indeed,  that  great  excess  of  soda  in  the 
blood  may  hinder,  or  even  arrest  the  tracheal  secretion,  but  those  who 
have  been  accustomed  to  employ  it  with  an  opposite  intention  may  reply 
that  they  only  use  small  doses,  or  else  local  applications,  by  means  of  an 
atomized  solution.  Perhaps  the  use  of  such  sprays  by  attenuating  the 
secretion  may  render  it  more  easy  to  expel.  Inhalations  of  ammonia  or 
of  vinegar  are  considered  by  Petronne  as  rational  in  chronic  dry  catarrh, 
but,  of  course,  as  inadmissible  in  acute  cases.  When  the  membrane  was 
bathed  with  these  liquids  it  caused  extensive  hyperaemia  and  much  secre- 
tion. Astringents  within  four  to  six  minutes  he  found  produced  great 
pallor  of  the  membrane.  His  observations  with  nitrate  of  silver  on  the 
tracheal  membrane  of  rabbits,  guinea-pigs,  and  dogs  are  interesting  :  he 
used  a  solution  up  to  four  per  cent.,  which  dried  the  epithelium  and  com- 
pletely arrested  secretion,  but  he  was  able  to  satisfy  himself  that  there 
was  no  diminution  in  the  vascularity.  On  the  other  hand,  in  the  phar- 
ynx and  the  nasal  cavity  the  four  per  cent,  solution  produced  a  consider- 
erable  excess  in  the  secretion  of  the  mucous  glands  in  these  regions, 
but  in  the  larynx  the  same  solution  in  the  course  of  half  an  hour  pro- 
duced dryness  ;  hence,  inhalations  of  tannin  or  alum  may  be  used  as 
astringents,  but  applications  of  nitrate  of  silver  will  differ  in  their  effects 


PNEUMATICS.  219 

according  to  the  part  of  the  menibrane  to  which  they  are  applied.  A 
spray  of  spirits  of  turpentine  on  a  small  portion  of  membrane  diminished 
and  soon  arrested  secretion,  but  a  watery  solution,  one  or  two  per  cent., 
gave  rise  to  hyper-secretiou  and  vascular  depletion,  thus  completely  con- 
hrming-  Rossbach's  statements.  This  property  of  calling  forth  secretion 
and  at  the  same  time  producing  anaemia  of  the  membrane  is  as  important 
as  it  is  interesting-,  and  enables  us  to  understand  the  favorable  influence 
of  terebinthinate  sprays  and  vapors  in  chronic  catarrh  and  thickening  of 
the  membrane.  With  apomorphia,  pilocarpine,  and  emetia,  experimenting 
upon  dogs  and  cats,  he  produced  swelling  of  the  tracheal  membrane  with 
a  glandular  condition,  and  so  much  secretion  in  the  respiratory  tract  that 
crepitant  rales  were  heard  all  over  the  chest,  and  section  of  the  nerves 
did  not  prevent  these  phenomena.  He  considers  that  pilocarpine  pro- 
duces secretory  troubles  through  the  whole  system  and  should  therefore 
be  used  with  caution,  but  like  the  other  expectorant  alkaloids  may  be 
useful  in  dry  catarrh  and  croup.  As  to  their  antagonists,  atropia  and 
morphia,  he  entirely  confirms  Rossbach.  Atropia  completely  checks  the 
secretion  in  forty  or  fifty  minutes,  but  increases  the  vascularity,  and  as 
section  of  the  laryngo-tracheal  nerve  does  not  prevent  the  phenomena 
the  action  of  the  alkaloid  may  be  exerted  upon  the  mucus-forming  cells 
and  the  terminal  nerve-filaments. 

The  preceding  account  of  Rossbach's  and  Petronne's  experiments 
upon  animals  may  perhaps  be  appropriately  followed  by  a  briefer  state- 
ment of  some  of  my  researches  on  the  subject  of  exriectorants.  It  may 
be  stated  at  the  outset  that  my  experience  very  largely  corroborates 
their  statements,  though  some  differences  may  yet  have  to  be  accounted 
for.  My  observations  have  been  made  upon  patients  chiefly  with  the  aid 
of  the  laryngoscope,  but  in  the  pharynx  and  nostrils  this  is  unnecessary. 
In  all  cases,  however,  reflected  light  has  been  employed.  The  parts  have 
been  painted  with  solutions  in  some  cases,  in  others  they  have  been 
treated  with  vapors  and  atomized  sprays.  Comparing-  the  results,  I  have 
not  been  able  to  satisfy  myself  as  to  the  effect  of  soda,  partly,  perhaps, 
because  the  solution  was  not  of  the  same  strength.  I  have  never 
regarded  this  bicarbonate  as  specially  expectorant,  whether  employed 
locally  or  administered  internally.  Potash,  however,  promotes  secretion, 
and  is  therefore  a  useful  ingredient  in  expectorant  mixtures  ;  not  only 
the  bicarbonate,  but  the  citrate,  and  I  think  also  the  nitrate,  possesses 
this  property.  Some  of  the  salts  of  lithia  are  also  endowed  with  similar 
virtues  :  under  the  influence  of  these  salts  the  secretion  becomes  thinner 
and  more  abundant,  while  congestion  abates.  But  the  most  remarkable 
salt  in  this  respect  is  iodide  of  potassium,  the  action  of  which,  when 
taken  internally,  is  obvious  in  the  nasal  passages,  the  pharynx,  and 
larynx.  Further,  by  auscultation,  it  may  be  demonstrated  to  act  also 
on  the  bronchial  membrane.     When  the  system  is  saturated  and  severe 


220  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

iodism  produced,  it  is  perfectly  true  that  a  state  of  congestion  may  be 
set  up,  but  at  an  earlier  stage,  or  rather  under  the  influence  of  small 
quantities,  or  when  solutions  are  painted  on  the  part,  or  sprays  inhaled, 
there  is  seen  rather  the  exudation  of  a  considerable  quantity  of  thin, 
watery  mucus,  with  no  increase  of  vascularity,  and  sometimes  even  a 
little  pallor.  This  salt  is  therefore  expectorant,  promoting  the  bronchial 
secretion,  as  also  may  be  incidentally  remarked  it  does  that  of  the  sali- 
vary fflands.  As  to  such  irritants  as  ammonia  and  acetic  acid,  I  can  en- 
tirely confirm  the  statements  quoted.  So  I  can  for  the  most  part  what 
has  been  said  of  astringents,  but  these  agents  differ  somewliat  atnong 
themselves,  some  do  not  appear  to  produce  the  oj^acity  described  by 
Rossbach,  unless  the  solutions  are  very  concentrated,  and  all  of  them  may 
be  so  diluted  as  to  prevent  this  result  and  yet  retain  their  power  to  di- 
minish secretion  and  vascular  fulness.  I  have  applied  tannin  to  the  mem- 
brane of  the  larynx,  in  both  weak  and  highly  concentrated  solutions, 
with  the  result  of  reducing  vascularity  and  secretion.  In  the  pharynx 
the  effect  is  much  less  obvious  ;  in  the  nasal  passages  it  is  more  marked, 
and  this  and  other  weak  astringents  may  be  applied  in  the  same  manner 
and  the  effect  observed  with  the  rhinoscope.  As  a  rule  it  may  be  stated 
that  only  weak  solutions  should  be  experimented  with  in  this  region. 
The  result  of  applying  nitrate  of  silver  with  a  brush  differs  very  greatly 
in  different  parts,  as  well  as  in  different  proportions.  I  have  employed 
the  nitrate  in  solutions  varying  from  one  grain  to  sixty  in  the  ounce,  in 
a  few  instances  one  hundred  and  twenty  grains,  and  various  proportions 
between.  These  concentrated  solutions  are  of  course  caustic.  Milder  ones 
produce  opacity  of  the  membrane  and  arrest  secretion  ;  still  weaker  solu- 
tions, and  sometimes  very  weak  ones,  produce  in  the  larynx  a  sensation 
of  drvness,  which  arises  from  diminished  secretions  as  well  as  a  diminu- 
tion of  vascular  fulness.  In  the  nasal  cavity  and  in  the  pharynx,  per- 
haps as  a  secondary  effect,  congestion  follows  the  application  of  ten  to 
twenty  grain  solutions,  accompanied  by  hyper-secretion,  and  this  even 
when  the  application  is  confined  to  a  small  area. 

Pilocarpine  and  emetia  internally  are  decided  expectorants,  but  the 
former  is  not  well  adapted  to  be  used  for  this  purpose  in  ordinary  cases, 
though  the  latter  may  be  made  to  replace  ipecacuanha.  I  have  no  con- 
clusive experiments  as  to  the  local  application  of  pilocarpine,  but  as  to 
ipecacuanha  and  its  alkaloid  can  confirm  their  expectorant  qualities. 
On  the  other  hand,  apomorphia  I  have  tried  locally  with  very  decided  re- 
sults, as  well  as  administered  it  internally.  It  produces  a  considerable  in- 
crease in  the  secretion,  with  little  if  any  diminution  of  vascularity,  and  is, 
therefore,  an  excellent  simple  expectorant,  and  may  also  be  given  as  such 
internally  in  very  small  doses.  For  the  last  two  or  three  years,  in  conse- 
quence of  the  result  of  experiments,  I  have  been  using  apomorphia  as  a 
spray  to  relieve  preternatural  dryness  and  irritability  of  the  larynx,  and 


PNEUMATICS.  221 

can  recommend  it  for  this  purpose.  In  a  case  in  which  incessant  cough 
had  been  a  most  serious  complication  for  many  weeks,  exhausting  the 
patient — a  phthisical  one — and  defeating  all  the  efforts  of  the  medical  at- 
tendants, a  spray  of  apomorphia  produced  more  relief  than  any  other 
remedy,  local  or  general,  and  in  distinctly  laryngeal  cough,  with  a  pre- 
ternaturally  dry  membrane,  even  when  congestion  was  present,  the  local  use 
of  this  alkaloid  has  been  of  great  service,  apparently  by  provoking  a  fresh 
flow  of  thin,  unirritating  mucus.  The  power  of  apomorphia  to  produce 
considerable  bronchial  secretion,  when  given  internally,  has  been  con- 
firmed by  Jiirgensen  and  Wertner,  who  have  given  it  in  bronchitis,  pneu- 
monia, and  oedema  of  the  lungs,  with  good  results. 

With  atropia  my  results  are  exactly  antagonistic  to  those  observed 
with  apomorphia.  It  is  very  easy  to  check,  and  even  to  arrest  the  se- 
cretion by  means  of  atropia  ;  it  acts  as  promptly  and  certainly  on  the  laryn- 
geal membrane  as  it  does  in  arresting  salivation.  In  from  half  to  three- 
quarters  of  an  hour  the  membrane  may  be  dried  and  rendered  hyperremic. 
This  may  be  effected  by  a  hypodermic  injection  or  by  a  local  application  ; 
it  is  obvious  that  the  latter  should  be  made  with  considerable  circumspec- 
tion, on  account  of  the  potency  of  this  alkaloid.  It  would  not  do  to 
paint  the  ordinary  solution  with  a  laryngeal  brush.  Morphia,  though  less 
powerful  and  perhaps  less  rapid,  also  diminishes  the  secretion,  but  it  does 
not  in  ordinary  quantities  cause  hyperjemia  ;  it  is  difficult  to  completely 
arrest  secretion  by  opiates.  With  regard  to  the  combined  action  of 
morphia  and  atropia,  it  is  scarcely  necessary  to  add  anything  to  the 
statements  which  I  have  advanced  in  the  sections  on  opium  and  bella- 
donna in  a  former  chapter.      [Vide  Neurotics.) 

It  is  commonly  said  that  expectorants  are  rather  uncertain  in  their 
action.  This  is  not  surprising  if  we  are  to  include  among  them  all  the 
groups  we  have  described,  and  then  regard  them  all  as  acting  in  the  same 
way,  or  look  upon  the  respiratory  surface  as  a  medium  for  the  action  of 
evacuants.  This  membrane  ought  not  to  be  regarded  as  an  emunctory, 
and  it  is  fortunate  that  the  notion  of  evacuating  by  all  channels  has  pretty 
well  passed  away.  Nevertheless,  we  observe  that  gases  which  are  ordi- 
narily eliminated  by  the  bowels  do  sometimes  escape  through  the  respira- 
tory membrane  and  taint  the  breath,  and  so  it  is  not  surprising  that  other 
substances  finding  their  way  into  the  blood  should  be  removed  by  this 
channel,  though  at  other  times  they  are  eliminated  by  the  skin  or  kid- 
neys. The  uncertainty  complained  of  will,  to  a  considerable  extent,  dis- 
appear if  we  are  sufficiently  exact  in  the  selection  of  our  expectorants 
and  other  pneumatics  according  to  the  precise  effects  we  are  desirous  of 
producing.  Even  then,  however,  it  is  not  to  be  denied  that  a  great  ele- 
ment of  uncertainty  does  exist,  which  is  chiefly  due  to  the  difficulty  we 
experience  in  coping  with  the  many  grave  results  which  are  produced  by 
diseases  of  the  respiratory  organs. 


222  THERAPEUTICS    OF   THE    EESPIRATORY    PASSAGES. 

Expectorants,  and  indeed  all  the  pneumatics,  may  be  conveniently  di- 
vided into  two  groups  :  1,  those  which  are  applied  locally  to  the  mucous 
membrane,  that  is,  which  are  inhaled  as  gases,  fumes,  vapors,  or  spravs, 
or  which  are  brought  into  contact  with  accessible  portions  of  the  membrane 
as  in  the  case  of  gargles,  lozenges,  and  topical  medication  by  manipula- 
tive proceedings  ;  2,  those  which  are  administered  through  the  system, 
and  which  may  be  called,  therefore,  general  expectorants.  No  doubt,  as 
we  have  seen,  many  of  these  act  topically,  being  brought  to  the  part 
through  the  circulation  and  there  excreted,  at  any  rate  in  part.  But 
being  present  in  the  blood,  other  effects  in  the  system  may  also  be  pro- 
duced. Moreover,  the  several  members  of  the  group  act  through  differ- 
ent channels,  some  on  blood-vessels,  others  on  the  nerve-supply,  others 
on  the  glands  of  the  membrane,  others  circulating  in  the  blood  find  access 
to  the  medulla  and  act  upon  that,  and  others  may  perhaps  produce  their 
effect  by  acting  on  the  blood-plasma  or  the  red  corpuscles.  The  influence 
of  some  narcotics  is  very  general  ;  thus  opium  not  only  restrains  secre- 
tion and  affects  the  entire  respiratory  nervous  apparatus,  but  has  so  great 
an  influence  on  the  nervous  system  of  the  whole  body  as  to  make  its  in- 
fluence exceedingly  complex  and,  so  to  say,  universal.  So  we  find  other 
general  expectorants  exercising  such  important  influence  on  the  circula- 
tion that  their  effects  are  felt  throughout  the  system,  whether  as  stimu- 
lants or  depressants. 

We  propose  now  to  rearrange  in  a  few  useful  groups  the  principal 
respiratory  remedies — pneumatics — with  brief  comments  on  some  of  the 
more  important,  a  method  which  it  is  hoped  will  economize  space.  We 
will  begin  with 

GENERAL   EXPECTORANTS. 

These  augment  the  amount  of  secretion  poured  into  the  respiratory 
passages  by  stimulating  the  activity  of  the  secernent  function.  Their 
effects  upon  the  general  system  are  so  diverse  and  so  considerable,  espe- 
cially upon  the  circulation,  that  they  may  be  divided  into  groups  according 
to  their  general  effects,  which,  as  it  happens,  to  a  larg-e  extent  correspond 
with  their  local  action.  Three  groups  may  thus  be  arranged  ;  1,  De- 
pressants ;  2,  stimulants  ;  3,  alterants. 

1.  Depressant  Expectorants. — -The  most  important  of  these  are 
the  nauseants,  which  have  already  been  described  in  connection  with 
emetics,  as  in  large  doses  they  produce  vomiting.  Antimony  and  ipecac- 
uanha act  directly  and  indirectly  as  expectorants,  as  we  have  seen  they 
do  as  emetics  and  nauseants.  They  hold  an  almost  unique  place  as  de- 
pressant expectorants,  greatly  reducing  the  circulation,  and  so  are  of  more 
use  in  febrile  cases.  It  has  sometimes  been  thought  that  the  expecto- 
rant action  is  only  produced  as  a  result  of  the  nausea,  but  emetia  has  been 


PNEUMATICS.  223 

detected  In  the  secretion,  and  as  well  as  antimony  is  doubtless  partly- 
eliminated  through  the  respiratory  membrane  and  may  therefore  act  upon 
it  locally,  at  the  same  time  the  centre  is  depressed  as  well  as  the  circula- 
tion. Moreover,  an  expectorant  action  can  be  produced  in  doses  which 
are  insufficient  to  excite  nausea.  Anyone  with  large  experience  of  these 
medicines,  and  especially  of  antimony,  can  confirm  this  statement.  (See 
Nauseants  ) 

Apomorphia,  though  a  prompt  emetic,  and  chiefly  employed  for  that 
purpose,  also  possesses  expectorant  properties.  It  is,  however,  scarcely 
a  depressant,  except  through  the  vomiting  it  produces.  It  does  not  seem 
to  depress  the  circulation  as  a  necessary  part  of  its  own  influence,  for  in 
emetic  doses  the  pulse  may  rise  on  the  approach  of  nausea  and  reach  its 
highest  point  just  before  vomiting  begins,  falling  between  the  acts  of 
vomiting-.  Tlie  blood-pressure,  too,  is  not  lessened  by  its  action.  Further, 
it  stimulates  the  respiratory  centre,  and  thus,  as  shown  by  Dr.  Gee  '  and 
by  Siebert,''  greatly  accelerates  the  respiration.  From  these  observations, 
which  have  been  fully  confirmed  by  Quehl,^  Riegel  and  Boehm,^  Bour- 
geois,^ Dujardin-Beaumetz,"  Budin  and  Coyne,'  Brunton  {^Practitioner), 
and  others,  it  would  seem  that  in  itself  it  is  hardly  entitled  to  be  called  a 
depressant  expectorant,  but  neither  can  it  be,  perhaps,  considered  stimu- 
lant, at  any  rate  in  expectorant  doses.  Large  quantities  or  repeated 
doses  may  set  up  prostration  with  depression  of  the  respiratory  centre, 
causing  slow  and  shallow  respirations,  and,  as  Harnack  '  proved,  death 
from  their  gradual  secession  ;  there  may  then  be  a  rise  in  the  pulse-rate  and 
a  fall  of  temperature  of,  according  to  Ziolkowski,^  one-tenth  to  half  a  de- 
gree C,  though  Bourgeois  maintains  that  it  has  no  effect  on  the  temper- 
ature, and  Moerz  "  observed  a  rise  of  one-fifth  during  the  act  of  vomiting. 
After  section  of  the  vagi  the  respiration  is  more  accelerated,  so  the  effect 
appears  to  be  due  to  the  action  on  the  centre.  Carville  mentions  a  case 
in  which  three-tenths  of  a  grain  caused  prostration  and  collapse  in  an 
adult  (  Gaz.  Heh.,  1874);  another  is  reported  by  Prevost  {JMedical  Record, 
1875),  in  which  a  smaller  dose  produced  serious  collapse.  In  children, 
Harnack*  found  this  condition  easily  produced,  butLoeb  [Schmidt''  s  Jahrb.) 

'  Gee,  S.  :   Clinical  Society's  Transactions.     1869. 

'  Siebert,  V. :   Untersuchungen  iiber  die  pliysiologisclien  Wirkungen  des  Apomor- 
phins.     1871. 

'  Qnehl,  Max  :   Ucber  die  pliysiologisclien  Wirkungen  des  Apomorphins.     1872. 

*  Riegel  and  Boelim  :   Deutsclies  Arcliiv  fiir  klin.  Med.     1872. 

*  Bourgeois,  J.    B.   V.    :    De  rapomorpliine   Reclierclies  cliniques   sur  uii   nouvel 
emetique.     1874. 

^  Dujardin-Beaumetz  :  Note  sur  Paction  tlierapeutique  de  I'Apomorpliine.     1874. 
■'  Budin  and  Coyne  :    Sur  certains  effets  de  I'Apomorpliine.     1875. 
8  Harnack  :  Archiv.  exp.  Path.  u.  Ther. ,  Bd.  ii. 
'  Ziolkowski :   Apomorpliin.     1872. 
'"  Moerz,  A.  :  Prager  Vierteljalir.     1872. 


224  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

injected  0.002  grain  under  the  skin  of  an  infant  thirteen  months  old  suf- 
fering from  capillary  bronchitis  ;  it  produced  free  vomiting,  by  which  the 
child  was  much  exhausted.  Occasionally  without  causing  vomiting  apo- 
morphia  has  produced  unpleasant  and  even  alarming  symptoms.  Some- 
times these  appear  to  have  been  due  to  the  use  of  a  solution  which  had 
become  green,  a  change  it  soon  undergoes.  It  is  therefore  desirable  to 
use  only  fresh  solutions. 

Lobelia  and  tobacco  are  both  powerful  depressant  expectorants. 
They  kill  by  depressing  the  respiratory  centre.  The  active  principles, 
lobelin  and  nicotin,  are  very  powerful  depressing  and  irritating  poisons. 
They  are  quickly  eliminated,  chiefly  through  the  kidneys.  Both  medi- 
cines have  been  said  to  be  expectorant,  but  are  not  much  used  as  such. 
Lobelia  is  reputed  to  possess  a  considerable  power  over  spasm  of  the 
bronchial  muscles,  and  for  this  reason  is  esteemed  by  some  physicians, 
who  give  from  ten  to  twenty  drops  of  the  tincture  every  quarter  of  an 
hour  until  nausea  is  produced,  in  order  to  arrest  paroxysms  of  asthma. 
Others  give  as  much  as  a  drachm,  and  repeat  it  in  two  hours  if  no  relief 
follow.  But  these  large  doses  sometimes  produce  alarming  collapse, 
and  their  effect  must  be  closely  watched.  Ten  minims  of  the  ethereal 
tincture  may  be  added  to  expectorant  mixtures  when  there  is  a  ten- 
dency to  bronchial  spasm.  Lobelia  is  a  powerful  irritant  of  the  stomach 
and  bowels,  and  has  been  sometimes  popularly  used,  probably  on  this 
account,  but  it  has  given  rise  to  a  number  of  fatal  results.  Even  under 
medical  supervision  grave  symptoms  have  frequently  arisen,  especially 
in  weakly  or  young  patients.  Indeed,  it  ought  not  to  be  given  to  chil- 
dren, and  altogether  is  not  a  remedy  in  which  I  have  much  confidence. 

2.  Stimulant  Expectorants. — These  include  {ci)  substances  which 
act  directly  on  the  membrane,  those  (i)  which  stimulate  the  centre,  and 
(c)  those  Avhich,  though  exercising  an  influence  over  the  respiratory  or- 
gans, excite  the  circulation.  Sometimes  general  stimulants  become  ex- 
pectorants, as  by  sustaining  the  system  for  a  time  they  either  promote 
the  bronchial  secretion,  or,  more  important  still,  in  the  cases  in  which 
they  are  required,  enable  the  patient  to  expel  it.  Hot  beverages  and 
liquid  nutrients  assist  in  fulfilling  these  indications.  In  other  instances 
exercise  and  gymnastics  are  anpropriate.  Alcohol,  ether,  essential  oils, 
terebinthinates,  and  oleo-resins  find  their  place  here.  Stimulants  of  the 
centre,  like  belladonna  and  strychnia  may  also  be  used  with  a  view  to 
sustaining  respiration  and  assisting  the  removal  of  the  sputa. 

Ammonia  and  its  carbonate  are  powerful  general  stimulants  with 
expectorant  properties,  operating  on  the  central  nervous  system  and  es- 
pecially stimulating  the  respiratory  and  cardiac  centres.  As  a  volatile 
stimulant  ammonia  may  be  supposed  to  determine  toward  the  respira- 
tory membrane,  but  it  appears  to  be  oxidized  in  the  system,  at  least  a 
portion  of  it,  and  to  escape,  as  shown  by  Bence-Jones  ("  Phil.  Trans.," 


PlfEUMATICS.  225 

1851)  by  the  kidneys.  A  small  quantity  injected  into  the  blood  of  an 
animal  greatly  accelerates  the  respiration.  Not  only  does  section  of  the 
vagi  fail  to  prevent  this,  but  the  change  from  the  slow,  deep  breathing 
of  divided  vagi  to  the  extremely  rapid  breathing  of  ammonia-poisoning 
is  most  remarkable.  The  increase  in  the  pulse  is  chiefly  due  to  the  effect 
on  the  cardiac  centre,  though  it  also  exercises  a  powerful  but  evanescent 
stimulant  action  on  the  heart.  On  injection  into  the  veins  Lange  found 
a  momentary  fall  of  arterial  pressure,  followed  by  an  enormous  sudden 
rise,  corresponding  with  the  increase  of  the  pulse-rate,  and  which  by 
other  experiments  {Archiv  f.  exper.  Path.  u.  T/ier.)  he  showed  to  be 
due  to  an  effect  upon  the  heart  itself,  or  on  the  peripheral  vaso-motor 
nerves,  or  on  the  muscular  fibres  in  the  coats  of  the  arteries.  In  poison- 
ous quantities  Funke  found  the  heart  was  quickly  paralyzed  [PJiueger^s 
Archiv).  Felz  and  Ritter  {Jahr.  de  VAnatomle  et  de  la  Phys.,  1874)  ob- 
served that  the  red  corpuscles  were  injured  in  a  dog  killed  by  ammonia. 
As  an  expectorant  the  carbonate  is  generally  employed,  and  is  appropri- 
ate in  feeble  patients  when  the  secretion  is  tenacious  and  difficult  to 
raise.  By  sustaining  the  centre  it  improves  the  coughing  power,  and 
enables  the  patient  to  get  rid  of  the  accumulation.  It  is  therefore  in 
the  bronchitis  of  old  and  weakly  people,  in  pneumonia  when  the  heart 
is  failing,  or  when  it  occurs  in  the  course  of  typhoid,  that  it  is  most  ap- 
propriate. In  short,  it  is  as  a  general  stimulant,  with  a  very  special 
action  on  the  respiratory  centre,  as  well  as  on  the  circulation,  that  it  is 
most  valuable.  That  it  also  does  affect  the  bronchial  membrane  seems 
to  be  shown  by  the  fact  that  in  some  instances  of  death  by  poisoning 
this  membrane  has  been  found  intensely  congested.  It  is  often  added 
to  other  expectorants,  such  as  senega,  in  order  to  increase  their  effects. 
Compare  its  action  with  other  respiratory  stimulants. 

Scilla. — Hippocrates  employed  squill  (o-KiXAa)  for  various  purposes, 
and  Pliny  describes  (lib.  xix.,  cap.  30)  two  sorts,  and  mentions  that 
Pythagoras  had  written  a  treatise  on  the  medicinal  virtues  of  squill  and 
invented  the  acetmn.  Durastantes  '  extolled  this  preparation  in  1567, 
Alberti  ^  and  Schuize  '  recommend  it  in  asthma,  and  Brichenden  *  says 
that  in  his  time  it  was  used  in  both  asthma  and  dropsy.  Its  action  as  a 
diuretic  was  discussed  by  Cullen  ^  and  Home,"  while  Vogt '  contrasted  it 

'  Durastantes,  J.  M.  :  Libri  duo  Medici,  i.,  De  Aceti  Scillini  compositione  mirificis, 
ob  saiiitatem  ac  vitam  duitissime  producendam  viribus,  ac  congruo  usu.     15C7. 

2  Alberti,  M.  :   De  Sqnilla.    1722. 

^  Schiilze,  J.  H.  :  Disp.  sistens  aegrotum  Asthmaticum  nsu  radicis  Scillae  sublevatum. 
3737.     Also,  Examen  chemicum  radicis  Scillge  mariiiEe.     1739. 

*  Brichenden,  J.  :   De  radice  Scillse.     1759. 

*  Cullen,  W.  :   Treatise  Materia  Medica.     1789. 

*  Home  :  Clinical  Experiments.     1783. 

'  Vogt  :  Lehrb.  d.  Pharmakodyn.     1828. 
15 


226  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

with  digitalis.  The  diuretic  effect  was  naturally  noticed  before  the  ex- 
pectorant, but  the  latter  has  been  well  established.  It  was  also  early 
recognized  that  scilla  is  very  irritant,  full  doses  causing  nausea,  vomiting, 
and  perhaps  purging.  In  toxic  quantities  inflammation  and  even  gan- 
grene of  the  stomach  and  intestines  have  been  seen  and  strangury  and 
convulsions  have  occurred. 

Scilla  is  a  powerful  stimulant  of  the  mucous  membrane,  we  may  per- 
haps say  of  all  the  mucous  membranes,  but  it  exercises  a  special  influence 
on  the  bronchial  surface,  where  scillain  has  been  shown  to  be  eliminated. 
It  is  further  entitled  to  a  place  among  the  stimulant  expectorants  as  it 
possesses  a  very  decided  action  on  the  heart,  in  respect  to  which,  as  well 
as  to  its  diuretic  qualities,  it  may  be  compared  to  digitalis,  with  which, 
indeed,  it  is  very  often  advantageously  combined.  The  force  of  the  car- 
diac contraction  is  increased  by  this  medicine,  but  not  the  frequency, 
which  is  rather  retarded.  At  the  same  time  contraction  of  the  periph- 
eral vessel  is  produced,  with  a  rise  in  the  blood-pressure.  This  is  followed 
by  relaxation,  which  mostly  begins  in  the  renal  arterioles,  and  thus  ac- 
counts for  the  diuretic  action.  Squill  increases  both  the  secretion  and 
the  vascularity  of  the  bronchial  membrane  ;  it  is  therefore  contra-indi- 
cated in  acute  cases.  Active  congestion  of  this  membrane  becomes  acute 
inflammation  under  the  influence  of  scilla.  It  is  true  that  in  strong  per- 
sons it  may  seem  to  do  good,  for  by  increasing  the  amount  of  secretion 
and  at  the  same  time  rendering  it  thinner  this  remedy  may  facilitate  its 
expulsion  and  so  give  rise  to  a  deceptive  appearance  of  relief,  while  it  is 
in  reality  aggravating  the  disease.  But  in  chronic  cases  with  some  pas- 
sive congestion  it  may  be  very  appropriate.  In  relaxed  conditions  of  the 
membrane,  in  leuco-phlegmatic  constitutions,  and  in  aged  or  debilitated 
patients,  when  the  expectoration  is  viscid  and  raised  with  difficulty,  pro- 
vided the  skin  be  cool,  soft,  and  moist,  and  the  pulse  sloWj  soft,  or  weak, 
the  best  effect  may  be  obtained.  If  the  right  heart  should  be  at  the  same 
time  secondarily  affected,  the  remedy  will  l)e  still  more  applicable,  as  it 
will  act  favorably  in  sustaining  the  circulation.  But  if  the  pulse  be  hard 
and  quick,  and  the  expectoration  purulent,  there  is  considerable  risk  of 
its  doing  mischief.  It  is  quite  possible  that  in  such  a  case  it  may  indi- 
rectly benefit  a  strong  patient,  by  exciting  a  profuse  secretion  and  thereby 
unloading  the  capillaries.  In  doubtful  cases  it  may  be  combined  with 
antimony  or  with  refrigerants  ;  but  when  these  are  required  it  is  usually 
too  soon  to  begin  squills.  The  rule  is,  in  acute  inflammations  it  is  not  to 
be  given — nor  is  any  stimulant  expectorant.  Ipecacuanha,  it  is  true,  has 
a  stimulating  influence  on  the  membrane,  in  increasing  and  liquefying  the 
secretion,  but  in  the  doses  usually  prescribed  the  irritation  is  not  great 
and  the  other  qualities  of  this  drug  make  it  a  depressant  expectorant. 
Scilla  is  apt  to  derange  digestion,  and  may  therefore  be  inadmissible  when 
otherwise  indicated   lest  it   should   interfere  with   nutrition.       In   such 


PNEUMATICS.  227 

cases  combinations  with  ammonia,  belladonna,  or  carminatives  may  be  em- 
ployed, or  these  and  other  remedies  substituted,  with  perhaps  minute 
doses  of  ipecacuanha,  reserving  the  squill  for  a  later  period. 

Senega  was  introduced  as  a  remedy  for  the  bites  of  snakes  and  other 
venomous  creatures  by  Dr.  Tennent,'  a  Scotch  physician,  residing  in 
Pennsylvania  in  1738,  and  soon  after  we  find  from  C.  Linnaeus  °  that  it 
had  been  employed  in  fevers  and  inflammations,  and  he  considered  it 
diuretic.  By  1782  Hellmuth  '  was  able  to  collect  remarks  from  various 
writers  as  to  its  use  in  pleurisy,  pneumonia,  hydrothorax,  asthma,  rheu- 
matism, dropsy,  etc.;  it  was  considered  to  promote  most  of  the  secre- 
tions, and  therefore  was  employed  in  numerous  diseases.  But  it  has 
failed  to  maintain  its  reputation,  except  in  bronchial  affections,  and  in 
these  it  is  still  confidently  prescribed.  Sundelin  *  took  twenty  grains  of 
the  powder  every  two  hours  for  three  doses  ;  he  found  it  greatly  irri- 
tated the  back  of  the  tongue  and  throat  and  increased  the  flow  of  saliva. 
A  little  later  it  caused  burning  at  the  epigastrium,  nausea,  and  vomiting, 
as  well  as  griping  pains  and  watery  purging.  The  gastric  uneasiness 
with  loss  of  appetite  lasted  three  days.  The  skin  was  rendered  warmer 
and  moister,  and  diuresis,  with  a  feeling  of  heat  in  the  urinary  passages 
was  produced.  Larger  doses  caused  violent  vomiting  and  purging,  with 
giddiness  and  anxiety.  It  appears  to  excite  the  vascular  system,  and  to 
stimulate  all  the  mucous  membranes  ;  but  its  chief  value  is  for  its  effect 
on  the  respiratory  membrane.  Its  irritant  quality  has  caused  the  pow- 
der to  be  used  as  an  errhine,  but  it  is  internally  that  it  is  chiefly  em- 
ployed. It  promotes  the  secretion  of  the  bronchial  membrane,  and  ren- 
ders it  less  tenacious.  It  is  believed  to  stimulate  the  circulation  in  that 
membrane,  as  well  as  the  nerves,  so  that  it  assists  the  expulsion  of  the 
sputa,  and  is  therefore  a  valuable  stimulating  expectorant,  acting  in  both 
ways.  Senega  also  acts  upon  the  heart  in  the  same  way  as  squill  and 
foxglove,  diminishing  the  frequency,  but  not  the  force  of  the  beat  ;  prob- 
ably, also,  it  affects  the  circulation,  and  through  this  may  be  diuretic. 
It  contains  saponin,  which  has  some  analogies  with  digitonin,  and  may 
be  perhaps  identical  with  it.  This  active  principle  is  locally  very  irri- 
tating and  affects  the  whole  circulatory  and  nervous  systems  ;  it  is  ex- 
creted by  the  bronchial  membrane  (which  perhaps  explains  the  expec- 
torant action  of  senega)  as  well  as  by  the  skin  and  kidneys,  both  of 
which  it  stimulates  to  increased  action.  As  a  diuretic  it  increases  the 
amount  of  the  solid  constituents  of  the  urine  as  well  as  the  water. 

So  powerful  a  stimulant  to  the  respiratory  membrane  is  to  be  avoided 


'  Tennent,  J.:  On  the  Rattle-snake  Root.     1738.     Also,  Epistle  to  Dr.  Mead  con- 
cerning the  Efficacy  of  the  Seneca  Snake  Root.     1743. 
^Linnaeus,  C. :   Radix  Senega.     1749. 
"  Hellmnth,  L.  C:  De  radice  Senega.     1783. 
^  Sundelin  :  Handb.  d.  spec.  Heilmittell. 


228  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

in  acute  inflammatory  conditions.  It  may  even  be  capable  of  convert- 
ing congestion  into  inflammation.  In  pneumonia  and  piitiiisis  it  is  also 
as  a  rule  too  stimulating.  As  it  irritates  the  stomach  and  bowels,  it  is 
desirable  to  avoid  it  where  the  digestion  is  easily  disordered  and  when 
there  is  a  danger  of  impairing  nutrition.  Moreover,  most  persons  con- 
sider it  nauseous,  so  much  so  that  many  decline  to  take  it.  Its  greatest 
value  is  in  chronic  bronchitis,  in  debilitated  constitutions,  and  when  am- 
monia is  called  for.  The  infusion  then  forms  a  good  vehicle  for  car- 
bonate of  ammonia.  Some  persons  venture  to  give  it  before  the  febrile 
stage  has  completely  passed  by,  but  most  observers  admit  that  it  is 
much  better  at  a  later  period.  Some  have  so  much  faith  in  its  specific 
action  on  the  membrane,  that  in  order  to  obtain  that  at  an  earlier  period, 
i.e.,  before  they  would  venture  to  give  it  alone,  they  give  with  it,  or  at 
the  same  time,  small  doses  of  antimony.  This,  of  course,  increases  the 
tendency  to  vomiting  which  is  produced  by  the  senega,  and  it  would  be 
more  rational  and  more  in  accordance  with  the  knowledge  we  have  ob- 
tained of  its  action  to  postpone  its  use  until  antimony  becomes  no  longer 
appropriate. 

Turpentine. — Several  terebinthinates  have  been  employed  from  an 
early  period,  though  it  is  not  easy  to  identify  the  particular  plants  spo- 
ken of  by  ancient  writers.  Probably  the  pistachia  terebinthus  is  the 
terebinthus  of  the  ancients  (the  T€p/i,iV^o9  of  Dioscorides  and  Theo- 
phrastus).  Oil  of  turpentine  is  a  powerful  stimulant  to  the  various 
mucous  membranes,  and  also  to  muscular  fibre  ;  it  is  largely  excreted  by 
the  lungs  and  kidneys,  perhaps  also  to  some  extent  by  the  intestines. 
Some  of  it  passes  out  through  the  skin,  and  an  eruption  is  occasionally 
produced  by  it  ;  it  is  extremely  irritant  to  the  kidneys,  which  fact  pre- 
vents its  being  used  when  otherwise  it  is  indicated  ;  but  it  has  been  em- 
ployed in  many  very  different  diseases.  It  is  a  depressant  of  the  ner- 
vous system,  an  effect  which  begins  to  manifest  itself  as  soon  as  the 
reflex  stimulant  influence  has  been  produced.  A  full  dose  produces,  after" 
preliminary  excitement,  dulness,  drowsiness,  and  unsteady  gait,  and  a 
larger  quantity,  coma.  At  the  same  time  the  heart  is  interfered  with, 
and  the  blood-pressure  falls.  These  facts  may  perhaps  explain  the  re- 
markable power  of  turpentine  to  arrest  haemoptysis,  and  other  forms  of 
internal  hemorrhage  ;  a  full  dose  sometimes  acting  like  a  charm,  when 
all  astringents  have  failed.  This  effect  may  perhaps  be  partly  due  to  an 
effect  upon  the  vessels.  In  the  bronchial  walls  it  appears  to  affect  the 
vascular  supply,  and  also  the  muscular  fibres.  It  must  also  be  a  disin- 
fectant to  the  sputa,  and  for  this  reason  is  useful  in  chronic  bronchitis, 
bronchiectasis,  and  pulmonary  gangrene.  Locally  we  know  that  the 
fumes  of  terebinthinates  and  allied  substances  have  long  been  found  to 
exercise  an  important  influence  on  the  respiratory  membrane.  This  local 
influence  is  no  doubt  e.\ercised  upon  the  capillaries,  glands,  and  nerves  of 


PNEUMATICS.  229 

the  membrane  during  the  exhalation  of  the  remedy,  which  imparts  its 
own  odor  to  the  breath. 

The  inconvenience  attending  the  administration  of  oil  of  turpentine 
is  derived  not  from  its  effect  on  the  gastro-pulmonary  membrane,  but  on 
the  o-enito-urinary  tract,  to  which  it  determines,  and  also  on  the  kidneys, 
which  it  greatly  irritates,  even  small  quantities  often  giving  rise  to  lum- 
bar pain,  diminution  or  sometimes  suppression  of  urine,  strangurj'',  and 
haematuria.  Although,  therefore,  it  has  been  used  as  a  diuretic,  and  is 
generally  speaking  antispasmodic,  any  excess  in  the  dose  produces  oppo- 
site effects,  and  it  is  often  necessary  to  omit  its  use  on  account  of  renal 
irritation.  Besides  these  symptoms  toxic  doses  often,  but  not  invariably, 
occasion  vomiting  and  purging.  The  giddiness  and  intoxication  which 
succeed  the  preliminary,  no  doubt  largely  reflex,  excitement  rapidly  pass 
into  a  state  of  extreme  depression.  Complete  unconsciousness  comes  on 
in  some  cases  with  dilated  pupils,  the  pulse  becomes  rapid  and  weak, 
and  the  respiratory  centre  fails.  At  a  very  early  period  the  effect  on 
the  renal  organs  was  observed,  Ranchin,*  in  1640,  having  given  us  an  ac- 
count of  the  violet  odor  imparted  to  the  urine  by  the  remedy,  and  Wil- 
helmi  '  gives  an  account  of  its  use  in  diseases  of  this  membrane  and  com- 
pares it  with  balsams.  Durand  '  a  century  afterward  recommended  it 
in  biliary  calculi.  During  the  present  century  the  properties  of  the 
medicine  have  been  more  carefully  studied  and  its  position  among  thera- 
peutic agents  determined. 

AH  the  turpentines  properly  so  called  are  odorous  exudations  from 
the  stems  of  trees  belonging  to  the  coniferas  ;  some,  as  frankincense,  are 
solid,  others,  like  Canada  balsam,  liquid  ;  all  of  them  are  mixtures  in  va- 
rious proportions  of  volatile  oils  and  resins,  these  can  be  separated  by 
distillation.  Thus  pure  oil  of  turpentine,  sometimes  improperly  called 
spirit  or  essence  of  turpentine,  is  the  volatile  oil  obtained  from  various 
species  of  pinus  by  distillation  from  the  crude  exudation,  the  solid  resin 
being  left.  When  freshly  distilled  the  pure  oil  is  colorless  and  limpid, 
but  on  exposure  to  the  air  it  absorbs  oxygen,  gets  yellowish  and  thicker, 
and  a  resin  is  produced.  Moreover,  it  converts  part  of  the  oxygen  into 
ozone,  for  which  reason  it  is  employed  in  the  guaiacum  process  for  de- 
tecting blood.  The  oil  is  very  slightly  soluble  in  water  and  less  soluble 
in  alcohol  than  most  volatile  oil,  it  is,  however,  readily  taken  up  by 
ether  ;  in  its  turn  it  dissolves  fixed  oils  and  fats,  resins,  india-rubber,  etc. 
Prepared  from   different  sources  it  behaves   differently  toward  polarized 

'  Ranchin,  P.  :  Traite  curieux  sur  I'odeiir  de  la  violette  que  les  Terebinthines  don- 
nent  aux  urines.     1640. 

^  Wilhelmi,  J.  :  De  Terebinthina.     1699. 

^  Durand,  J.  P. :  Observations  sur  I'efficacite  d'un  melange  d'Ether  sulfurique  el 
d'Huile  volatile  de  Terebeutliiue  dans  les  Coliques  Hepatiques  produites  pars  des 
pierres  biliares,     1790. 


280  THERAPEUTICS    OF   THE    RESPIRATORY   PASSAGES. 

light,  but  commercial  samples  often  consist  of  a  mixture  of  several  oils. 
Pure  oil  =  C,o  Hj^  and  is  therefore  isomeric  with  many  other  essential 
oils,  and  is  resolvable  into  terebine,  cymene,  a  campiioraceous  body,  col- 
ophene,  etc.  We  have  dwelt  thus  particularly  on  its  properties  on  ac- 
count of  its  intimate  relations  with  other  essential  oils  and  allied  reme- 
dies, some  of  which  we  will  now  notice.  Firwood  oil,  obtained  from  the 
pinus  sylvestris,  may  be  regarded  as  identical  with  common  turpentine, 
but  rather  less  disagreeable  in  flavor. 

Essential  oils  are  rather  complex  compounds,  possessing  powerful 
odors  of  very  various  kinds,  many  of  which  are  greatly  esteemed  for 
their  agreeable  flavor  and  fragrance.  They  contain  campliors,  turpenes, 
resins,  etc.,  and  are  allied  to  balsams  and  gum  resins  on  tlie  one  side  and 
to  carbolic,  benzoic,  and  cinnamic  acids  on  the  other.  Many  of  them  at 
a  low  temperature  separate  into  a  solid  camphor-like  body  called  stearop- 
tene  (o-rcap,  fat,  tttt^vos,  volatile),  and  the  pure  fluid  hydro-carbon  eloeop- 
tene  (c'Aatov,  oil,  ttttjvos).  We  may  make  three  groups  :  (a)  Pure  hydro- 
carbons or  non-oxygenated  turpenes,  isomeric  with  oil  of  turpentine, 
C,„  Hjg,  examples  of  this  group  are  oil  of  junij)er,  lavender,  peppermint, 
cloves,  and  several  others  ;  ip)  oxygenated,  of  which  cinnamon,  caraway, 
etc.,  furnish  examples  ;  (c)  those  which  contain  besides  C  and  H  a  pro- 
portion of  S,  whether  with  or  without  N,  these  are  marked  by  their  pow- 
erful and  often  fetid  odor,  as  in  the  case  of  oils  of  mustard,  horseradish, 
and  assafoetida. 

Essential  oils  are  partly  excreted  by  the  pulmonary  mucous  mem- 
brane and  stimulate  it  in  a  manner  resembling  turpentine  and  camphor, 
and  may  therefore  sometimes  be  substituted  as  more  agreeable  medicines. 
As  we  have  seen,  they  differ  considerably  among  themselves  in  fragrancy, 
flavor,  and  other  qualities.  And  so  they  do  in  their  therapeutical  value, 
but  they  may  all  be  regarded  as  weakly  antiseptics,  as  stimulants,  and 
antispasmodics,  and  inasmuch  as  they  are  eliminated  to  some  extent 
through  the  bronchial  membrane,  claim  to  be  regarded  as  expectorants. 
Many  of  them,  however,  exert  their  principal  effect  on  the  alimentary 
membrane,  exciting  the  nerves  of  taste  and  smell,  promoting  the  flow  of 
saliva,  stimulating  the  stomach,  and  increasing  appetite  ;  they  are  there- 
fore commonly  called  carminatives  and  stomachics.  The  muscular  coat 
is  also  stimulated,  and  the  consequent  contractions  expel  flatus  and  re- 
move the  pain  caused  by  distention  ;  they  are  therefore  in  a  sense  anti- 
spasmodic. This  stimulating  influence  extends  along  the  intestines  and 
some  of  them  are  highly  prized  in  colic  and  as  corrigents  of  purgatives. 
They  enter  the  blood  and  directl}'  excite  the  whole  nervous  system, 
though  perhaps  some  of  their  stimulating  influence  may  be  regarded  as 
reflex.  The  pulse  rises  in  force  and  frequency  ;  under  their  influence  the 
blood-pressure  is  also  raised,  but  these  remedies  are  not  often  given  in 
doses  sufficient  to  affect  the  circulation  or  to  be  much  felt  through  the 


PNEUMATICS.  231 

general  nervous  system.  They  are  excreted  by  all  the  mucous  membranes, 
chiefly  through  the  kidneys  and  bronchial  membrane,  upon  which,  as  we 
have  said,  they  may  exercise  their  special  effect  while  being  eliminated. 

Oil  of  eucalyptus,  which  has  lately  been  so  largely  used,  is  antiseptic, 
and  being  excreted  by  the  kidneys  and  lungs  imparts  its  odor  to  their 
excretions,  disinfecting  them  and  at  the  same  time  stimulating  the  mu- 
cous surface  ;  it  has  therefore  been  freely  used  in  cystitis  and  pyelitis 
on  the  one  hand,  and  on  the  other  much  more  freely  in  bronchitis, 
asthma,  and  other  respiratory  affections.  Oil  of  anise  has  generally  been 
held  to  determine  toward  the  respiratory  membranes,  while  the  mints, 
cloves,  pigments,  caraway,  coriander,  etc.,  most  affect  the  alimentary 
membrane,  and  juniper  is  a  diuretic  and  is  identical  with  turpentine  in  its 
composition  and  specific  gravity,  and  resembles  it  in  imparting  a  violet 
odor  to  the  urine.  Garlic,  onions,  leeks,  and  other  strong-smelling  vege- 
table substances  employed  in  cookery,  owe  their  qualities  to  their  essen- 
tial oil,  and  have  long  had  a  popular  reputation  as  expectorants  in  chronic 
catarrh.  In  some  districts  raw  onions  are  eaten  by  elderly  sufferers  from 
bronchitis,  under  the  belief  that  they  help  their  winter  cough,  and  with 
the  same  view  leeks  and  garlic  are  freely  used  in  their  diet. 

Camphor  may  be  regarded  as  an  oxidized  product  of  an  essential  oil, 
or  a  stearopten  ;  its  formula  is  C,„H,gO,  and  it  has  so  distinct  an  effect 
on  the  bronchial  mucous  membrane,  through  which  it  is  eliminated  un- 
changed, that  it  has  long  enjoyed  a  popular  reputation  in  catarrh  and 
other  affections,  the  powder  being  even  used  as  snuff.  In  moderate 
quantities  it  does  not  give  its  odor  to  the  breath,  and  it  is  not  eliminated 
as  such,  but  in  a  changed  condition  through  the  kidneys.  It  is  somewhat 
antiseptic  and  generally  regarded  as  a  diffusible  stimulant  and  antispas- 
modic. In  ordinary  doses  it  is  rapidly  absorbed  and  apparently  rapidly 
decomposed,  and  does  not  produce  a  great  effect,  but  in  full  doses  its 
chief  action  is  on  the  brain,  where  it  may  produce  giddiness,  drowsiness, 
and  a  species  of  intoxication.  (  Cf.  Neurotics.)  Oil  of  camphor  is  a  hy- 
drocarbon C,„Hj5,  isomeric  with  oil  of  turpentine,  and  possessing  in  a 
high  degree  the  odor  and  other  qualities  of  camphor. 

Canada  balsam  is  the  turpentine  which  exudes  from  the  balm  of 
Gilead  fir — abies  balsamea.  It  has  sometimes  been  given  internally,  for 
the  same  purposes  as  ordinary  turpentine,  and  is  believed  to  be  less  irri- 
tating. It  is  not  a  true  balsam,  but  yields  a  volatile  oil  on  distillation. 
Fine  specimens  are  sometimes  sold  as  balm  of  Gilead,  which,  however, 
is  the  product  the  balsamodendron  opobalsamum.  Other  turpentines  have 
also  been  used,  and  they  all  possess,  though  in  different  degrees,  similar 
qualities. 

Iialsam.s. — The  true  balsams  are  the  fragrant,  resinous  substances  which 
contain  benzoic  or  cinnamic  acids,  and  all  of  them  have  some  claim  to  be 
considered  expectorants.     In  the  Pharmacopoeia  we  have  four  true  bal- 


232  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

sams,  viz.  :  benzoin,  storax,  and  the  balsams  of  Peru  and  Tolu,  Copaiba 
is  not  a  balsam,  but  an  oleo-resin,  as  is  Canada  balsam.  lialsam  of  Peru, 
though  a  stimulating  tonic  and  expectorant,  is  not  much  used  internally 
in  the  present  day.  Like  its  allies  it  may  be  considered  antiseptic,  it 
seems  also  to  be  a  nervous  sedative.  lialsam  of  Tolu  possesses  similar 
qualities,  but  its  flavor  is  much  more  agreeable,  and  consequently  it  re- 
tains its  place  as  a  valued  ingredient  of  cough-mixtures,  though  in  the 
quantities  in  vehich  it  is  mostly  employed  it  is  more  a  flavoring  ingredi- 
ent than  an  active  therapeutical  agent.  At  one  time  the  use  of  balsams 
and  other  somewhat  stimulating  substances  was  almost  universal,  but 
now  they  have  become  unduly  neglected,  and  certainly  in  chronic  bron- 
chitis, winter  cough,  and  any  old  standing  affections  of  the  respiratory 
membrane,  and  in  bronchitic  asthma  they  deserve  attention.  They  began 
to  be  neglected  from  the  time  when  Dr.  Fothergill '  pointed  out  the  evils 
that  might  follow  their  indiscriminate  use,  about  one  hundred  years  ago. 
But  Trousseau  and  Pidoux"  have  expressed  considerable  confidence  in 
them  as  remedies  in  chronic  bronchial  catarrh,  though  in  the  present 
day  it  is  their  local  use  which  is  most  trusted. 

Benzoin  is  not  named  by  ancient  writers  in  such  a  way  as  to  enable 
us  to  identify  it,  but  it  must  have  been  known  at  an  early  period,  and  has 
long  been  used  in  incense.  It  seems  to  have  been  confounded  with  other  bal- 
sams, all  of  which  were  believed  to  exercise  considerable  influence  and  were 
highly  valued  as  medicines.  In  1530  Perez^  wrote  a  treatise  upon  their  use. 
In  1592  Alpinus^  distinguished  some  of  them,  and  in  1597  Guibert^  pointed 
out  the  distinction  between  benzoin  and  myrrh. 

Eenzoin  is  the  most  irritating  of  the  balsams,  therefore  the  most 
likely  to  derange  the  digestion  ;  its  effect  on  the  respiratory  mucous 
membrane  resembles  that  of  the  others,  but  it  is  more  stimulating  and 
therefore  should  be  avoided  where  there  is  any  degree  of  irritation.  In 
chronic  cases,  in  leuco-phlegmatic  constitutions  it  may  be  employed. 
Benzoic  acid  has  also  been  used  internally  for  this  as  well  as  other  pur- 
poses, as  well  as  topically.  Storax  was  well  known  to  the  ancients  ;  it  is 
mentioned  by  Hippocrates,  Theophrastus,  Dioscorides,  and  later  on  by 
Galen,  under  the  name  (TTvpa^,  and  Pliny  calls  it  styrax.  The  source  of 
this  and  some  other  drugs  related  to  it  have  been  carefully  investigated 
by  the  late  Daniel  Hanbury,"  whose  papers  on  such  subjects  are  full  of 

'  Fothergill,  John  :    Works,  edited  by  Lettsom.     1783. 
^  Trousseau  et  Pidoux  :    Traite  de  thorapeutique.     Third  edit.  1874. 
^  Perez.  G.  :  De    Balsamo,  j  de  sus  utilidades  para  les  enfermedades  del  cuerpo 
humano      1.530. 

*  Alpinus,  Prosper :  De  Balsamo  Dialogiis  ;  in  quo  verissima  balsami  plantse,  Opo- 
balsami,  Carpobalsami  et  Xylobalsami,  cognitio  elucesoit.     1.592. 

*  Guibert,  N. :   De  Balsamo  ejnsque  lachryma  quod  Opobalsataum  dicitur.     1603. 

*  Hanburj,  Daniel,  F.R.S. :  Science  Papers.     1876. 


PNEUMATICS.  233 

information  and  interest.  The  therapeutical  use  of  styrax  is  the  same 
as  the  other  balsams. 

Gum  Eesins. — Olibanum  and  myrrh  are  both  of  great  interest  on  ac- 
count of  their  long  history  and  the  immense  value  at  one  time  attached 
to  them.  Olibanum,  the  Lebonah  of  the  Jews,  the  Luban  of  the  Arabs, 
the  Xt)3ai/os  and  Xt/Javwros  of  the  Greeks,  was  doubtless  the  frankincense 
of  the  ancients.  It  is  mentioned  in  the  book  of  Exodus  (xxx.,  34).  It 
contains  a  volatile  oil  besides  gum  and  resin.  It  was  long  regarded  as 
most  useful  in  chronic  mucous  discharges,  particularly  those  of  the  respi- 
ratory membrane,  and  was  also  employed  in  other  chest  affections,  even 
in  hfemoptysis  ;  it  may  be  regarded  as  a  stimulating  expectorant  and  is 
most  efficacious  as  a  fumigation.  Myrrh  was  a  most  important  article  of 
commerce  at  the  very  dawn  of  history,  the  company  of  Ishmaelites  who 
bought  Joseph  from  his  brethren  "  came  from  Gilead  with  their  camels 
bearing  spicery  and  balm  and  myrrh,  going  to  carry  it  down  to  Egypt " 
(Genesis  xxxvii.,  25).  Its  Hebrew  name  is  mahr  ("''?),  most  likely  in 
allusion  to  its  bitter  taste  ;  the  Greeks  called  it  cryaupra,  and  in  the  ^olic 
dialect  fxvppa.  Hippocrates  valued  it  in  several  diseases  and  Dioscorides 
described  several  kinds.  But,  notwithstanding  the  early  period  at  which 
the  product  was  known  and  its  importance  as  an  article  of  commerce,  we 
had  no  accurate  account  of  the  tree  which  produces  it  until  quite  modern 
times. 

An  interesting  account  of  this  investigation  has  also  been  given  by 
Hanbury.'  Guibert "  distinguished  it  from  benzoin,  for  Haller,  speaking 
of  his  work,  says,  "  Agit  de  myrrha,  de  vino  myrrhato,  de  benzoino  ;  negat 
pocula  myrrhina  facta  fuisse  ex  benzoino,  et  benzoina  myrrha  differre  do- 
cet."  In  the  next  century  Polisius  '  collected  a  curious  account  of  the 
uses  of  this  drug  and  the  numerous  formulte  in  which  it  was  employed, 
an  example  followed  by  an  English  writer*  at  the  commencement  of 
the  present  century. 

Myrrh  promotes  the  appetite  and  is  considered  as  a  good  stomachic. 
Like  the  other  remedies  to  which  it  is  related  it  appears  to  be  eliminated 
by  the  mucous  membranes,  upon  which  it  acts  as  a  moderate  stimulus.  In 
large  doses  it  may  irritate  the  stomach  and  cause  a  degree  of  pyrexia 
with  a  full  pulse  and  a  feeling  of  warmth  in  the  respiratory  passages, 
but  it  does  not  appear  to  possess  to  any  extent  the  nervine  and  anti- 
spasmodic properties  of  the  fetid  gum-resins,  such  as  assafoetida,  galba- 
num,  etc.     It  is,  however,  considered  more  distinctly  tonic,  in  which  it  is 

'  Hanbury,  D.  :   Op.  cit. 

^  Guibert,  N. :  Assertio  de  murrhinis,  sive  de  iis  qufe  murrhino  nomine  exprimun- 
tur,  adversiis  quosdam  de  iis  minus  recte  disserentes.     1597. 

^  Polisius,  G.  S.  :   Myrrhologia  seu  myrrhae  disquisitio  curiosa.      1688. 

■*  Stackhouse,  J.  :  Extracts  from  Modern  Authors  respecting  the  Balsam  and  Myrrh 
Tress.     1815. 


234  THERAPEUTICS    OF    THE    EESPIRATORY    PASSAGES. 

distinguished  from  the  balsams.  In  chronic  bronchitis  it  may  therefore  be 
useful.  It  has  been  lauded  in  phthisis,  in  which  it  was  supposed  to  check 
purulent  expectoration,  but  it  is  more  likely  to  prove  injurious  in  this 
disease,  at  any  rate  in  large  doses.  It  has  been  much  employed  in  gar- 
gles and  mouth-washes  ;  it  may  be  considered  somewhat  antiseptic. 

Halm  of  Gilead,  the  balm  of  the  Old  Testament,  the  BaXcra/Aov  of 
the  Greeks,  also  called  balm  of  Mecca,  once  so  highly  valued,  is  now  sel- 
dom employed  in  Europe,  but  in  Asia  still  retains  its  reputation  both  as 
a  medicine  and  a  perfume.  It  contains  a  volatile  oil  and  its  properties 
are  closely  allied  to  the  terebinthinates. 

Hdelliwn  is  the  name  applied  to  two  gum-resins,  one  of  them  proba- 
ably  the  bdellium  of  the  Bible,  also  called  Indian  bdellium,  or  false  myrrh, 
the  other  called  African  bdellium  ;  the  former  is  the  more  fragrant  and 
resembles  myrrh,  the  latter  contains  a  volatile  oil.  Neither  are  now 
much  use^. 

Ammoniacum  still  retains  considerable  repute  as  a  stimulant  expecto- 
rant, and  in  this  respect  is  perhaps  overrated,  being  scarcely  superior  to 
several  of  the  almost  obsolete  gum-resins  and  interior  to  the  fetid  ones. 
Two  kinds  have  been  described,  and  that  used  by  the  Greeks,  a./i,/iwvta/coi/, 
differs  from  the  article  now  in  use.  Pliny  says  it  grew  near  the  temple 
of  Jupiter  Amnion,  to  which  the  name  has  been  traced,  but  others  think 
it  quite  as  likely  that  it  is  only  a  corruption  of  armeniacum,  having  been 
probably  imported  through  Armenia.  From  Abu  Mansur  Mowafik  ben 
Ali '  we  learn  that  it  was  found  in  Persia  as  early  as  the  tenth  century. 
It  is  mentioned  by  various  writers,  Greek  and  Roman,  from  the  first  to 
the  thirteenth  century,  as  an  incense  or  fumigation,  thymiama  and  suffi- 
men. 

Ammoniacum  is  decidedly  a  local  irritant,  and  large  doses  are  there- 
fore apt  to  disturb  the  stomach.  It  appears  to  be  eliminated  by  the 
mucous  membranes,  upon  which  it  acts  as  a  stimulant.  It  contains  a 
small  quantity  of  volatile  oil,  which  probably  escapes  through  the  lungs 
and  accounts  for  its  stimulant  action  on  the  respiratory  membrane.  The 
irritation  of  the  skin  produced  by  the  plaster  would  seem  to  be  due  to 
the  resin.  In  the  small  doses  usually  given  it  can  hardly  be  considered 
to  have  much  action  on  the  system,  but  full  doses  are  apt  to  cause  vomit- 
ing and  purging  by  their  local  irritating  action.  In  chronic  bronchial 
catarrh  and  in  asthma,  and  in  some  cases  of  emphysema  if  there  is  a  good 
deal  of  secretion  from  a  relaxed  condition  of  the  membrane,  it  sometimes 
appears  to  be  useful,  though  Trousseau  and  Pidoux  [op.  cit.)  took  it  in 
doses  of  two  drachms  without  producing  anv  effect,  local  or  general.  It 
is  certainly  less  efficacious  than  the  fetid  gum  resins.      Cullen  "^  preferred 

'  Liber  Fundamentoriim  Pharmacol ogiae.     1055. 

2  Cullen,  W.  :   First  Lines  of  the  Practice  of  Physic.     1784.     Fourth  ed. 


PNEUMATICS.  235 

assafoetida  as  an  expectorant,  and  when  any  antispasmodic  influence  is 
desired  it  would  be  well  to  combine  it  with  one  of  its  more  disagreeable 
allies. 

These  /etid  gum  resins  have  held  a  distinct  place  in  materia  medica 
from  the  earliest  times,  and  are  still  valued  as  possessing  very  distinct 
properties,  dependent,  probably,  for  the  most  part  on  the  essential  oil 
which  can  be  obtained  by  distillation.  In  spite  of  what  we  consider  their 
extremely  disagreeable  odor  they  have  been  and  are  prized  in  the  East 
for  this  very  property,  and  have  sometimes  been  employed  among  us  in 
cookery,  though  only  in  the  most  minute  quantities.  The  most  impor- 
tant and  the  strongest  is  assafoetida.  Although  undoubtedly  used  by  the 
ancients  the  history  is  not  very  clear,  on  account  of  the  confusion  between 
it  and  the  succus  cyreniacus.  It  seems  as  if  it  had  been  introduced  as  a 
substitute  for  the  cyrenian  juice,  probably  from  Persia,  the  word  assa 
corresponding  with  laser,  pointing  to  that  source,  but  Myrepsus,'  who 
lived  about  1227,  speaks  of  dcra<^iriSa. 

Assafoetida  is  a  nervine  stimulant,  antispasmodic,  and  may  be  re- 
garded also  as  expectorant.  In  truth  all  these  fetid  gums  might  very 
well  be  grouped  together  as  antispasmodic  expectorants.  Some  have 
called  it  disinfectant,  as  such  it  would  be  a  good  illustration  of  a  more 
powerful  odor  overpowering  a  weaker  one,  and  so  obtaining  the  credit  of 
destroying  it.  It  is  readily  absorbed  and  is  eliminated  through  all  the 
secretions,  charging  them  with  its  disagreeable  smell.  It  exercises  a  de- 
cidedly stimulant  influence  on  the  mucous  membranes,  particularly  the 
bronchial,  through  which  a  considerable  portion  of  the  essential  oil  es- 
capes. So  completely  does  it  pervade  the  system  that  the  pus  of  super- 
ficial ulcers  has  been  observed  to  smell  strongly  of  the  drug.  .Joerg  ^ 
found  that  in  doses  of  twenty  grains  assafoetida  caused  in  healthy  per- 
sons irritation  of  the  stomach  and  bowels,  with  increase  of  the  secretion 
of  the  alimentary  membrane  and  of  the  fceces.  The  bronchial  secretion 
was  also  increased,  the  respiration  quickened,  and  together  with  this  the 
pulse  rose,  the  animal  heat  seemed  augmented,  and  perspiration  was  pro- 
moted. These  and  other  excitant  effects  were  verified  on  nine  healthy 
persons,  the  dose  in  no  case  exceeding  twenty  grains.  Nevertheless 
Trousseau  and  Pidoux  swallowed  half  an  ounce  for  a  dose,  with  no  other 
effect,  they  tell  us,  than  having  to  live  for  two  days  in  an  atmosphere 
more  horribly  fetid  than  the  drug  itself.  It  is  said  that  the  perspiration  of 
Asiatics  who  use  assafoetida  daily  is  verv  fetid,  a  circumstance  alluded  to 
by  Aristophanes,'  but  probably  it  is  the  breath  which  is  more  tainted  and 
distributes  the  odor  round  the  person,  though  there  is  little  doubt  that 

'  Myrepsus,  N.  :  Antidotarius,  cap.  xxvii.,  cited  by  Alston,  Materia  Medica,  vide 
Sprengel's  Hist. 

*  Joerg  :    Vide  Wibmer.  Werk.  d.  Arzneim.  u.  Gifte. 
^  Aristophanes :  Equites,  act  ii. ,  scene  4. 


236  THERAPEUTICS    OF    THE    KESPIRATORY    PASSAGES. 

the  skin  also  excretes  some.  As  a  stimulant  and  antispasmodic  expec- 
torant assafcetida  is  well  adapted  to  relieve  chronic  bronchial  disease,  at- 
tended with  dyspnoea  and  wheezing,  especially  in  old  and  weakly  persons 
where  the  disease  is  of  long  standing,  and  where  the  dyspnoea  is  some- 
what paroxysmal.  Another  class  of  cases  in  which  it  often  produces  bene- 
fit is  recurrent  bronchial  catarrh,  attended  with  wasting,  in  young  women 
who  seem  predisposed  to  phthisis  and  in  whom  debility  and  amenorrhoea 
cause  anxiety.  It  is  scarcely  as  an  expectorant,  however,  that  in  such 
cases  it  is  most  useful,  for  under  its  influence  the  bronchial  secretion 
often  diminishes  ;  but  there  is  no  doubt  that  the  effect  on  the  bronchial 
membrane  is  favorable,  it  may  almost  be  called  soothing,  and  the  other 
Avell-known  properties  of  the  drug  indicate  its  use.  Combinations  with 
ammonia,  where  a  more  stimulating  influence  is  needed,  are  most  valu- 
able and  should  be  used  when  the  circulation  is  languid.  In  pure  spas- 
modic asthma,  assafoetida  is  uncertain.  Cullen,'  who  placed  great  reli- 
ance on  the  drug  in  other  diseases,  found  it  of  no  benefit  in  this,  and  his 
opinion  is  indorsed  by  Pereira."  Still  it  may  often  be  advantageously 
taken  in  combination  with  other  remedies  between  the  paroxysms,  with  a 
view  of  giving  tone  to  the  respiratory  system,  especially  when  attacks 
are  provoked  by  damp.  It  is  more  useful  still  in  bronchitic  asthma.  In 
laryngismus  and  in  whooping-cough  it  has  been  very  strongly  recom- 
mended both  by  Millar '  and  Kopp,^  but  I  cannot  report  much  in  its 
favor,  and  it  is  difficult  to  persuade  children  to  take  it. 

Galbanum. — The  next  most  important  of  the  fetid  gum-resins  is 
mentioned  among  sweet  spices  in  the  book  of  Exodus  (xxx.,  34).  It  was 
used  by  Hippocrates  and  other  Greeks.  Dioscorides  spoke  of  -^aXjiavy]  as 
the  produce  of  fxerwTnov,  which  grew  in  Syria.  Its  physiological  and  thera- 
peutical properties  resemble  those  of  assafoetida,  and  it  may  be  ranked 
between  that  drug  and  ammoniacum,  but  as  it  yields  more  essential  oil  than 
either  it  has  been  supposed  to  be  more  excitant  to  the  circulation.  Clini- 
cal observation  does  not  support  this  idea,  and  it  may  be  that  the  oil, 
though  greater  in  quantity,  is  of  a  less  powerful  kind.  It  is  decidedly 
less  antispasmodic  and  probably  less  expectorant,  and  for  the  most  part 
only  employed  in  combination  with  its  more  powerful  ally. 

Similar  observations  may  be  made  respecting  Saga2yennm,  the  o-aya- 
TTtyjv^v  of  Hippocrates  and  Dioscorides,  the  sacopenium  of  Pliny,  which, 
so  far  as  the  respiratory  membrane  is  concerned,  may  be  ranked  between 
assafoetida  and  galbanum,  though  it  may  be  remembered  that  it  acts  more 
decidedly  on   the  alimentary  mucous  membrane,  and  has  therefore  been 


'  Cullen,  W.  :  Treatise  on  Materia  Medica.     1789. 
*Pereira,  J.  :  Elements  of  Materia  Medica  and  Therapeutics.     1853. 
^Millar,  J.  :  Observations  on  the  Astlima  and  the  Whooping-cough.     1769. 
*Kupp:  London  Medical  Gazette,  vol.  i. 


PNEUMATICS.  237 

used  as  a  warm  aperient  in  constipation  with  flatulence.  The  essential  oil 
has  a  strong  odor  resembling  garlic,  and  a  bitter  garlicky  taste,  which  is 
shared  by  the  resin. 

Opoponax  was  also  employed  by  the  Greek  fathers  of  medicine,  who 
mention,  some  three  and  others  four,  kinds  under  the  names  Trai/a/ccs  and 
oTTOTTavo^.  Dioscorides,  who  describes  three  kinds  of  the  gum-resin,  gives 
a  good  account  of  opoponax  {oiroirava^),  wlrich  he  tells  us  was  procured 
from  the  Trdi/aKcs  rjpdKXaov.  In  composition  this  resembles  the  preceding 
gum-resins  and  is  most  like  ammoniacum  in  its  properties  ;  it  may  often 
be  advantageously  combined  with  this,  and  though  excluded  from  the 
British  Pharmacopoeia,  perhaps  deserves  a  place  as  much  as  a  number  of 
other  little  used  substances.  The  essential  oil  is  eliminated  through  the 
lungs  and  acts  on  the  bronchial  membrane,  stimulating  it  to  increased 
secretion  but  not  often  appearing  to  irritate. 

Eleini,  apparently  a  word  of  Ethiopian  origin,  is  probably  derived 
from  several  of  the  terebinthaceae,  and  its  effects  are  similar  to  other  tere- 
binthinates,  but  it  is  abandoned  to  external  use.  The  ointment  is  some- 
times called  the  balm  of  Arcaeus,  being  a  substitute  for  an  ointment  in- 
troduced by  that  writer.' 

Copaiba  has  sometimes  been  employed  in  bronchial  affections,  instead 
of  some  of  the  other  oleo-resins,  and  Armstrong,''  Halle,  Bretonneau,^ 
Bayle,^  and  others  have  recommended  it,  but  it  has  no  superiority  to  the 
other  substances,  is  extremely  disagreeable  to  take,  sometimes  gives  rise 
to  severe  gastric  irritation,  and  on  account  of  its  associations  and  of  its 
affecting  the  bronchial  less  distinctly  than  the  urinary  passages  is  better 
abandoned  to  the  treatment  of  diseases  of  the  latter. 

Mastich,  obtained  from  the  Island  of  Scio,  also  contains  a  volatile  oil, 
and  so  possesses  in  some  degree  the  properties  of  the  terebinthinates. 
Highly  prized  for  centuries,  it  was  used  by  Hippocrates,  who  also  employed 
the  leaves  of  the  tree  a")^vov,  as  well  as  the  resin,  and  an  oil  obtained 
from  the  fruit.  It  is  scarcely  ever  now  used  in  medicine,  though  it  so 
long  enjoyed  a  high  reputation,  and  should  have  some  power  in  chronic 
affections  of  the  mucous  membranes. 

Inula  Helenium,  the  kXiviov  of  Hippocrates  and  Dioscorides,  our  ele- 
campane, is  an  aromatic  tonic  as  well  as  an  expectorant,  also  somewhat 
diaphoretic.  Thus  it  seems  to  promote  the  secretion  of  most  mucous 
membranes  and  of  the  skin.  In  large  doses  it  is  sufficiently  irritating  to 
cause  nausea  and  vomiting.  Its  action  resembles  that  of  senega,  but  it 
is  milder,  and  as  it  has  had  some  repute  as  a  tonic  in  dyspepsia  it  may 

'  Arcaeus  :   De  recta  Curand.   Vulner.   Ratione.     1658. 

■^  Armstrong,  J.  :  On  the  Efficacy  of  Copaiba  in  Inflammation  of  Mucous  Membranes. 
1823. 

^  Bretonneau ;  Memoire  sur  la  diphtherite. 

*  Bayle,  A.  L.  J.  :  Bibl.  de  Therapeutique.     1838. 


238  THERAPEUTICS    OF    THE    KESPIRATORY    PASSAGES. 

be  presumed  tliat  it  is  less  likely  to  irritate  the  stomach  than  senega,  and 
is  certainly  less  nauseous.  It  is  in  rather  chronic  bronchial  affections 
with  profuse  secretion,  in  the  absence  of  pyrexia,  that  it  is  most  likely  to 
be  useful.  The  name  inulin  has  been  sometimes  applied  to  a  substance 
resembling  starch  obtained  from  Helenium,  but  which  its  discoverer,  Rose, 
called  alantin.  The  active  principle  seems  rather  to  reside  in  a  camphor- 
aceous  body,  which  has  been*  called  alantol,  or  alant  camphor,  somewhat 
resembling-  menthol  in  taste  ^nd  smell. 

Larix. — This  interesting  tree  has  again  been  brought  somewhat  into 
notice  after  having  suffered  a  long  eclipse.  From  it  is  obtained  Venice 
turpentine,  to  which  wonderful  virtues  were  long  attributed,  and  which 
has  lately  acquired  a  sudden  but  ephemeral  notoriety.  Orenburgh  gum 
and  manna  de  Brian9on  were  also  the  products  of  the  larch.  Dr.  Frizel, 
of  Dublin,  introduced  the  inner  bark,  in  1858,  as  a  somewhat  stimulant 
medicine,  possessing  also  astringent  properties,  with  a  special  action  on 
mucous  membranes,  especially  the  bronchial,  and  a  tincture  of  this  bark 
has  found  its  way  into  the  Pharmacopoeia,  and  is  often  used  to  check 
profuse  expectoration  in  chronic  bronchitis.  It  has  also  been  used  in 
haemoptysis  and  other  hemorrhages.  Dr.  Stenhouse  obtained  from  the 
bark  a  volatile  active  principle,  which  he  could  not  find  in  other  pines, 
and  which  he  called  larixinic  acid,  on  account  of  its  reaction,  but  which 
some  have  termed  larixin,  an  inconvenient  name,  as  it  may  be  confused 
with  another  body  to  be  named  just  now.  The  common  larch  is  also  the 
source  of  a  fungus,  which  for  a  long  period  was  highly  valued,  the  agar- 
icus  laricis,  or  boletus  laricis,  or  boletus  officinalis,  boletus  purgans, 
polyporus  laricis  vel  officinalis,  as  it  was  variously  called.  This  fungus 
was  known  to  the  ancients,  Dioscorides  describing  it  under  the  name 
AyaptKov,  while  in  the  East  it  is  now  known  as  ayapiKov  ToXevKov  and  Karpav 
fxavTupi,  It  may  still  be  found  at  herbalists',  under  the  name  of  agaric, 
female  agaric,  white  agaric,  or  larch  agaric.  The  active  principle  has 
been  referred  to  the  resin,  but  Martins  '  isolated  a  white  amorphous  bitter- 
tasting  powder  which  he  termed  laricin.  The  resin  certainly  possesses 
irritant  qualities  and  is  purgative.  The  powder  of  agaric  is  a  local  irritant, 
causing  watering  of  the  e3'es,  sneezing,  cough,  etc.,  when  applied  to  the 
nostrils.  Swallowed,  it  acts  as  an  emetic  and  a  purgative,  causing  con- 
siderable nausea  and  griping,  but  its  most  important  use  was  to  arrest 
colliquative  sweating  in  phthisis.  De  Haen  recommended  it  for  this 
purpose,  and  Bisson  '  and  many  others'  reported  favorably  of  it,  includ- 

'  Vide  Bncliner's  Repertoriuin,  1846. 

^Bisson  :  Metnoire  sur  I'emploie  de  I'Agaric  blanc  contreles  sueurs  dans  ]a plitliis'a 
pulmonaire.  1832. 

^  Vide   Rubel,  J.  :  De  Agarico  offlcinali.    1778. 

Jacquin:    Diss,  de  Agarico  officinali.    1778. 

Murray,  J.  A.  :  Apparatus  Medicaminum,  tarn  simplicium  quam  compositorum. 
1776-90. 


PNEUMATICS.  239 

ing  Andral,  who,  however,  afterward  abandoned  it  as  of  little  use.  Tlie 
dose  of  agaric  was  from  three  grains  to  eight,  at  bedtime,  to  restrain 
sweating,  and  from  one-half  a  drachm  to  a  drachm  as  a  cathartic. 

Tar  and  its  derivatives  are  all  more  or  less  stimulant  expectorants, 
but  as  they  are  more  frequently  used  in  respiratory  diseases  for  their 
antiseptic  qualities,  they  will  be  considered  with  other  antiseptics  in  a 
separate  group. 

3.  Alterant  Expectorants. — These  are  chiefly  alkaline,  saline,  or 
antiseptic.  They  promote  the  secretion  of  the  bronchial  membrane,  but 
with  little  or  no  irritant  effect,  and  may  even  rather  depress  than  excite 
the  circulation. 

Alkalies. — Something  has  already  been  said  respecting  recent  experi- 
ments, which  tend  to  throw  doubt  on  the  long-acknowledged  power  of 
alkaline  carbonates  to  promote  bronchial  secretion  and  to  render  it  less 
viscid.  It  had  long  been  considered  certain  that  these  carbonates  were 
partially  eliminated  by  the  bronchial  membrane,  but  the  experiments 
alluded  to  cast  doubt  upon  this.  It  must  be  remembered,  however,  that 
the  injection  of  a  large  quantity  of  soda  into  the  blood  is  a  very  different 
thing  from  the  administration  of  moderate  medicinal  quantities.  Then 
it  may  be  remarked  that  soda  is  a  natural  constituent  of  the  blood,  and  a 
few  grains  more  or  less  would  scarcely  make  much  difference  by  the  mere 
fact  of  their  presence.  Clinical  observation  leads  me  to  regard  soda  as 
very  inferior  to  potash  as  an  agent  for  attenuating  the  sputa,  and  might 
almost  induce  me  to  admit  that  it  is  powerless  to  do  so.  But  the  local 
effect  on  some  mucous  membranes  resembles  that  of  potash,  though  it  is 
less  marked,  and  we  have  Virchow's  authority  for  stating  that  soda  stim- 
ulates the  movements  of  the  cilia,  and  sometimes  restores  them  after 
they  have  ceased.  Then  again  it  can  scarcely  be  forgotten  that  mucin, 
which  is  readily  precipitated  by  acids,  dissolves  freely  in  alkaline  fluids. 
Even  the  precipitated  form  of  mucin  is  easily  redissolved  by  alkalies. 

The  application  of  a  solution  of  a  potassium  salt  to  the  mucous  mem- 
brane of  the  mouth  increases  the  flow  of  saliva  and  even  causes  an  opac- 
ity in  the  fluid  which  has  been  conjectured  to  arise  from  alteration  of  the 
secreting  cells  ;  but  irritation  of  the  sympathetic  nerve-filaments  of  the 
submaxillary  gland  will  give  rise  to  the  same  appearance.  The  question 
is,  whether  the  bronchial  membrane  is  affected  in  the  same  way.  That 
some  potash  salts  affect  the  mucous  tissue  is  undeniable  from  their  action 
on  the  bowels.  Further,  their  effect  in  the  mouth  and  phar3mx  confirms 
the  general  observation  that  they  really  increase  the  bronchial  secretion 
and  render  it  more  fluid,  while  they  perhaps  increase  the  activity  of  the 
cilia  as  well  as  the  glands.  Gubler  conjectured  that  potash  antagonizes 
soda  in  the  blood  and  in  respiratory  combustion,  inasmuch  as  it  is  found 
normally  in  the  red  corpuscles. 

Chlorate  of  potash  has  enjoyed  a  considerable   reputation,   though 


240  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

partly  on  grounds  for  wliich  there  is  no  foundation.  It  has  been  largely 
used  in  croup  and  diphtheria,  but  does  not  deserve  confidence.  It  could 
not  be  expected  to  sufficiently  liquefy  the  exudation.  It  will,  however, 
sometimes  cause  a  degree  of  salivation,  and  in  bronchitis,  when  the  ex- 
pectoration is  viscid  and  scanty,  it  seems  to  give  relief  by  promoting  the 
flow  of  the  secretion  and  rendering  it  more  watery,  so  that  it  may  be 
termed,  perhaps,  an  alterant  expectorant.  Dr.  liaborde  '  says  that  it  both 
modifies  and  dilutes  the  expectoration  in  acute  and  chronic  bronchitis, 
and  Dr.  Sedgwick  ^  considers  it  useful  in  catarrh.  Koehler '  had  long  be- 
fore employed  it  in  phthisis,  but  without  obtaining  any  benefit,  though 
Dr.  Fountain  ■*  at  a  later  period  endeavored  to  revive  its  use  under  the 
notion  that  it  would  act  as  a  liberator  of  oxygen  in  the  system.  This 
idea  unfortunately  seems  to  have  prevailed  for  a  considerable  time  after 
it  was  shown  that  the  chlorate  is  eliminated  unchanged  by  the  kidneys. 
Wohler  ^  as  early  as  1824  reported  that  the  chlorate  among  other  salts 
passed  off  unchanged  in  the  urine,  and  his  observation  has  been  fully 
confirmed  ;  nevertheless,  the  idea  continues  from  time  to  time  to  crop  up. 
It  was  entertained  as  recently  as  1871  by  Baudrimont,"  and  has  several 
times  since  been,  complacently  stated  by  contributors  to  the  medical 
journals,  but  though  this  hypothesis  must  be  abandoned,  it  does  not  fol- 
low that  in  some  way  the  chlorate  may  not  be  of  some  service,  as  we 
know  that  other  salines  are.  That  it  may  affect  mucous  membranes  is 
natural  to  suppose,  since,  as  shown  by  Isambert,'  it  escapes  in  all  the  se- 
cretions, but  its  chief  value  is  undoubtedly  as  a  local  remed}'.  Dr. 
Harkin  ^  reported  that  it  improved  the  color  and  strength  of  some  phthisi- 
cal patients,  and  lessened  cough  and  diarrhoea.  The  late  Dr.  Symonds* 
seems  to  have  thought  that  it  could  promote  the  healing  of  a  cavity.  Dr. 
Spender '°  expresses    a  regret    that    its  value   in  phthisis    is   not  better 


'  Laborde,  J.  V.  :  De  la  valeur  du  Chlorate  de  Potasse  dans  le  traitement  des 
Glngivites  Clironiqnes,  etc.  1858.  Also,  Laborde,  J.  V.  :  Etude  comparative  de  Tac- 
tion pliysiologique  des  Chlorates  de  Potasse  et  de  Sonde,  des  Bromnres  de  Potassium 
et  de  Sodium.  Deductions  relatives  a  I'emploi  therapeutique  compare  de  ces  sub- 
stances     1875. 

^  Sedgwick,  L.  :  Britisli  Medical  Journal,  1873. 

'  Koehler :  Lancet,  1886-37. 

'•  Fountain,  E.  J.  :  On  the  Treatment  of  Phthisis  by  the  Chlorates  of  Potash,  with 
Observations  on  Oxygen  as  a  Therapeutic  Agent.     1860. 

'Wohler:  Zeitschrift  f .  Physiologie,  1824. 

*  Baudrimont,  E.  :  Eeeherches  sur  Taction  intime  des  substances  qui  aident  a  la 
decomposition  dii  Chlorate  de  Potasse  pour  en  degager  Toxygene.     1871. 

'  Isambert,  E.  :  Etudes  chimiques,  physiologiques,  et  cliniques,  sur  Temploi  thera- 
peutique du  Chlorate  de  Potasse,  spccialement  dans  les  Affections  Diphtheritiques.   1856. 

*  Harkin  :   Dublin  Medical  Quarterly  Journal,  1861. 
'  Symonds  :  British  Medical  Journal,  1868. 
"Spender:  Brit,  and  For.  Med.-Chirur.  Rev.,  1873. 


PNEUMATICS.  241 

known,  and  M.  Gimbert  *  endeavors  to  show  that  in  certain  forms  of  this 
disease  it  is  of  considerable  value.  On  the  other  hand  Dr.  Cotton,  in 
his  trials  at  the  Brompton  Hospital,  could  trace  no  definite  effects  to  the 
remedv,  though  sometimes  it  improved  the  condition  of  cachetic  patients, 
while  Dr.  Austin  Flint''  found  benefit  in  only  one  out  of  fourteen  cases. 
We  may  perhaps  be  permitted  to  infer  from  this  discordant  evidence 
that  like  other  salines  it  is  only  useful  in  those  conditions  of  the  sys- 
tem which  indicate  this  class  of  remedies,  and  this  is  the  conclusion  to 
which  my  own  experience  points.  That  in  considerable  doses  it  affects 
mucous  membranes  there  can  be  little  doubt,  and  the  way  in  which  it  does 
this  is  probably  by  a  local  effect  while  being  eliminated,  and  certainly  its 
great  power  as  a  topical  application  in  aphtha  and  other  affections  of 
these  membranes  is  not  to  be  denied,  and  gives  it  a  place  in  therapeutics 
quite  distinct  from  other  potash  salts.  It  may  also  be  here  observed  that 
the  chlorate  is  destitute  of  the  powerful  cardiac  depressant  action  pos- 
sessed by  the  nitrate.  With  regard  to  the  other  salts  both  of  soda  and 
potash  the  statements  already  made  will  suffice. 

Ammotiiuin  Chloride. — The  early  history  of  this  salt,  as  it  is  often 
told,  may  after  all  be  only  a  fable,  for  sal  ammoniac,  which  is  said  to  derive 
its  name  from  Ammonia,  the  name  of  a  district  of  Libya  where  stood  the 
oracle  of  .lupiter  Ammon,  though  mentioned  by  various  writers,  may  have 
been  only  rock-salt.  Besides,  this  district  has  been  said  to  have  obtained 
its  name  from  the  nature  of  the  soil  (a/Ajaos,  sand),  and  after  all  the  name 
may  have  been  derived  from  a/xfiwi,  a  word  of  Egyptian  origin.  Herod- 
otus, it  is  true,  mentions  sal  ammoniac  (aX?  d/x,/xa)via(cds)  as  found  in  this 
locality,  but  perhaps  the  name  was  applied  to  some  other  salt.  Dr. 
Royle  '  has  remarked  that  the  Hindoos  must  have  been  acquainted  with 
sal  ammoniac  ever  since  they  burnt  bricks,  as  they  now  do  with  the  ma- 
nure of  animals,  for  some  of  it  usually  crystallizes  at  one  end  of  the  kiln. 
Moreover,  they  seem  to  have  found  out  how  to  make  the  carbonate  from 
it,  and  from  them  the  Arabians  probably  learned  the  process.  Geber  * 
knew  the  method  of  purifying  it  by  sublimation.  Muys  ^  recommended 
it  in  doses  of  one  to  two  drachms  in  interniittents,  and  it  became  rather 
largely  used  for  various  purposes. 

The  older  writers  thought  that  chloride  of  ammonium  acted  as  a  seda- 
tive to  the  heart,  and  at  the  same  time  quickened  the  capillary  circula- 
tion. They  also  observed  that  it  increased  secretion,  especially  from  the 
mucous  membranes,  and  attributed  to  it  the  power  of  promoting  absorp- 

'  Gimbert :  De  I'emploi  du  Chlorate  du  Potasse  dans  certaines  formes  de  la  Phthisie 
Pulmonaire.     1872. 

-  Austin  Flint:  American  Journal  Medical  Sciences,  1861. 
'  Royle  :  Antiquity  of  Hindu  Medicine.     1837. 
*  Geber:  The  Works  of  Geber.    London,  1678. 

'MuTS,  W.  G.  :  De  Salis  Ammoniaci  Proeclaro  ad  Febres  Intermittentes  usu.    1716. 
16 


242  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

tion,  though  in  a  less  degree  than  mercury.  It  was  also  said  to  impover- 
ish the  blood,  but  in  ordinary  doses  no  impairment  of  the  plasticity  will 
be  noticed,  and  no  distinct  effect  on  the  circulation,  though  it  has  been 
shown  that  after  poisonous  doses  administered  to  animals,  the  blood  con- 
tained less  solids  than  normally,  Rabuteau  '  has  shown  that  it  probably 
passes  off  by  all  the  secretions.  He  found  it  speedily  in  the  saliva,  but  the 
major  portion  is  removed  through  the  kidneys,  and  he  was  able  to  recover 
from  the  urine  nearly  the  whole  amount  which  had  been  taken.  It  nota- 
bly increased  the  amount  of  urea,  and  Bocker  "  found  that  it  increased 
all  the  solids  of  the  urine  except  uric  acid,  which  was  slightly  diminished. 
In  Germany  sal  ammoniac  has  been  largely  prescribed  for  gastric  catarrh. 
In  England  it  is  chiefly  used  as  a  remedy  for  chronic  bronchitis,  and 
sometimes  for  acute  catarrh  ;  but  it  is  scarcely  appropriate  in  the  early 
stage  of  the  latter,  or  when  there  is  decided  pyrexia.  Perhaps  its  most 
appropriate  use  is  after  the  more  active  symptoms  have  subsided,  but  be- 
fore a  stimulant  expectorant  seems  called  for.  Dr.  Patton  commends  it 
{Practitioner,  vol.  vi.)  in  the  later  stages  of  pneumonia.  Some  writers 
seem  to  have  supposed  that  it  is  decomposed  in  the  system,  ammonia 
being  liberated  and  acting  as  a  stimulant,  but  there  is  no  foundation  for 
the  idea,  and  even  large  doses  have  no  exciting  effect.  Dr.  Copeland 
recommended  it  in  passive  hemorrhages,  and  Dr.  Warburfcon  Begbie  has 
used  it  for  this  purpose  with  success  {Lancet,  1875).  The  late  Dr.  Bei- 
gel  {Lancet,  1867)  arranged  an  apparatus  for  the  inhalation  of  freshly 
formed  chloride,  and  Liebermann  has  reported  favorably  of  a  similar  ap- 
paratus of  Loewin's  {Bull,  de  Therap.,  1873). 

Sulphur  has  been  known  from  the  earliest  ages,  it  is  mentioned  in  the 
Book  of  Genesis  (xvi.,  24)  and  in  Homer's  Jliad  (lib.  xvi.)  as  well  as 
other  ancient  writers.  It  passes  into  the  secretions  and  may  be  con- 
sidered a  mild  stimulus  of  the  skin  and  mucous  membranes,  particularly 
the  broncliial,  but  in  large  doses  it  acts  on  the  intestinal  lining.  Among 
other  uses  it  has  accordingly  been  employed  in  chronic  catarrh,  asthma, 
bronchitis,  croup,  diphtheria,  and  pneumonia.  Buchheim  and  some  others 
doubt  whether  it  really  increases  the  bronchial  and  cutaneous  secretions, 
but  it  is  difficult  to  shut  our  eyes  to  the  fact  ;  there  is  a  difference  of 
opinion  at  to  the  renal  secretion.  There  is  a  vast  amount  of  experience 
as  to  its  favorable  influence  in  respiratory  diseases.  It  was  a  recognized 
remedy  among  the  ancients.  Galen  sent  consumptives  to  breathe  the 
sulphurous  vapors  at  Etna.  It  acquired  the  name  of  Pectoral  Balsam. 
Dr.  Graves  and  many  others  expressed  confidence  in  its  favorable  influ- 
ence over  the  respiratory  membrane,  and  Duclos'  advocates  the  continued 

'Rabuteau:  L'Union  Medicale,  1871. 

-  Bocker,  F.  W.  :  Beitrage  zur  Heilkunde.     1849. 

»Duclos:  Bull,  de  Therap.,  1861. 


PISTEUMATICS.  243 

use  in  asthma  of  small  doses.  Biiiz  '  suggests  tiiat  the  bronchial  nerves 
may  be  soothed  by  the  direct  action  of  sulphuretted  hydrogen,  as  it  is 
excreted  through  the  membrane.  Many  mineral  waters  of  considerable 
repute  in  the  treatment  of  respiratory  diseases  are  supposed  to  owe  their 
virtues  to  the  sulphides  they  contain.'^  The  local  use  of  sulphur  will  be 
considered  further  on. 

Iodine  is  the  most  remarkable  of  all  the  alterative  expectorants.  As 
the  element  was  only  discovered  in  1811  and  introduced  a  few  years  later 
by  Coindet '  into  therapeutics  we  may  regard  it  as  a  conquest  of  the 
present  century,  but  before  this  remedies  containing  iodine  were  in  use  ; 
such,  for  instance,  as  burnt  sponge,  which  for  a  long  time  enjoyed  a  con- 
siderable reputation.  Iodine  is  also  present  in  many  mineral  waters. 
Indeed,  it  is  rather  widely  distributed  in  small  quantities  in  both  the  or- 
ganic and  inorganic  kingdoms,  as  may  be  seen  by  reference  to  Sarphati's  " 
list  of  substances  containing  it.  Of  course  a  medicine  so  potent  and,  as 
shown  by  Coindet  and  later  by  Lugol,^  of  special  value  in  scrofula,  was 
sure  to  be  employed  in  phthisis  and  other  diseases  of  the  respiratory  or- 
gans and  to  give  rise  to  a  very  considerable  literature  which  we  have  not 
space  to  examine.^ 

Topically  iodine  is  an  irritant,  and  the  vapor  when  inhaled  strongly 
stimulates  the  respiratory  membrane.  It  has  been  employed  at  times  ex- 
tensively for  this  purpose,  either  alone  or  in  combination  with  other 
stimulants  or  with  anodynes. 

Camphor  sprinkled  with  the  tincture  and  inhaled  is  a  jDopular  remedy 
for  coryza  ;  so  is  a  combination  of  iodine  with  carbolic  acid.  Combina- 
tions with  kreasote,  ether,  chloroform,  etc.,  have  their  uses,  but  it  should 
be  remembered  whenever  these  inhalations  are  employed,  the  iodine  may 
enter  the  system  and  produce  its  characteristic  effects.  Conversely  we 
may  administer  it  or  the  salts  by  the  stomach  for  the  purpose  of  influenc- 
ing the  respiratory  membrane. 

Iodine  is  quickly  taken  into  the  blood,  probably  as  iodide  of  sodium 
or  perhaps  as  an  albuminate  ;  it  passes  rapidly  to  all  the  tissues,  particu- 
larly to  the  lymphatic  glands  and  secreting  surfaces  ;  but  only  scantily 
to  the  nervous  centres.     It  would  appear,  therefore,  as  if  it  must  increase 


'  Binz :   Elements  of  Therapeutics. 

^Ticliborne  and  Prosser  James:   Mineral  Waters  of  Europe.     1883. 

^  Coindet,  C.  W.  :  Biblioth.  Univ.  de  Geneve,  vol.  xvi.  ;  also  Observations  on  the  Re- 
markable Effects  of  Iodine.     Trans,  by  Dr   J.  R.  Johnson.     1821. 

■*  Sarphati,  S.  E.  :  Commentatio  de  Iodic.     1835. 

"  Lugol,  J.  G.  A.  :  Memoires,  snr  Tiode,  etc.  1829-1831.  Also  trans,  by  O'Shaugh- 
nessy,  with  appendix,  1831. 

"  For  early  literature  see  Bayle's  Bibl.  de  Ther. ,  1828.  For  later  references  to  1854 
see  Titon,  H.  A.  :  Recherches  sur  I'absorption  et  la  valeur  therapeutique  des  prepara- 
tions lodees.     1854. 


244  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

tissue  metamorphosis,  but  in  medicinal  quantities  loss  of  weight  is  quite 
exceptional,  and  it  does  not  appear  to  increase  the  excretion  of  urea. 
It  has  been  conjectured  that  it  may  act  on  the  blood-plasma,  rather  than 
the  tissues,  or  that  it  may  spare  the  liver,  which  would  account  for  these 
results.  They  may,  however,  be  partially  due  to  the  rapidity  with  which 
the  medicine  is  eliminated.  It  is  found  very  soon  after  it  has  been  taken 
in  the  mucous  secretions.  It  appears  also,  though  later,  in  the  perspira- 
tion, bile,  and  even  the  milk.  It  seems,  in  fact,  rapidly  to  pervade  the 
system  and  to  be  as  rapidly  excreted  in  all  directions,  but  the  major  part 
is  removed  by  the  kidneys,  though  it  can  scarcely  be  termed  a  diuretic, 
and  it  is  found  in  the  secretions  chiefly  as  iodide  of  sodium,  but  a  portion 
of  this  salt  is  decomposed,  and  hence  the  free  element  exercises  its  local  ac- 
tion. Pereira  observed  that  the  pocket-handkerchiefs  of  iodized  patients 
had  a  distinct  odor  of  the  element. 

The  j^rominent  symptoms  of  iodism  show  the  eflPect  on  the  respiratory 
membrane,  on  the  whole  of  which  it  acts  powerfully.  Tlie  nasal  pas- 
sages are  perhaps  the  first  to  be  affected,  but  the  conjunct! vre  and  the 
frontal  sinuses  speedily  participate,  and  thus  we  have  sneezing,  profuse 
coryza,  and  watering  of  the  eyes,  with  often  distention  of  the  brow  and 
severe  headache.  Often  the  patient  complains  that  he  has  caught  a  vio- 
lent cold  and  the  watery  discharge  from  the  eyes  and  nose  saturates  his 
handkerchiefs.  The  effect  on  the  buccal  and  faucial  membrane  is  also 
obvious  in  the  coated  tongue,  flow  of  mucus,  swelling  and  redness  of  the 
gums,  palate,  and  tliroat.  Salivation  shows  the  stimulant  action  on 
the  glands  and  even  when  this  is  not  prominent,  the  continual  taste  of 
the  medicine  proves  that  it  is  being  secreted  in  the  saliva.  The  effect 
on  the  pharynx  and  larynx  gives  rise  to  irritation  in  the  throat,  a  sensa- 
tion of  heat,  and  eough  ;  the  burning  and  rawness  extend  along  the  tra- 
chea and  over  the  chest.  Further,  that  the  bronchial  membrane  is  also  en- 
gaged is  shown  by  the  coughing  up  of  a  frothy  mucus  or  a  larger  quantity 
of  a  more  liquid  secretion,  according  to  the  degree  of  iodism,  and  on  aus- 
cultation moist  rales  indicate  the  extra  fluid  in  the  tubes.  Thus  through- 
out the  respiratory  membrane  a  considerable  degree  of  congestion  is  pro- 
duced ;  but  at  an  earlier  stage,  or  in  the  milder  cases,  there  is  less  active 
congestion,  and  the  membrane  may  only  pour  out  a  quantity  of  thin, 
watery  mucus,  with  scarcely  any  increase  of  vascularity. 

Such  effects  would  seem  to  indicate  that  the  preparations  of  iodine 
in  appropriate  doses  must  be  regarded  as  true  expectorants.  When  the 
secretion  is  deficient,  the  membrane  dry,  and  perhaps  swollen,  the  cough 
painful,  frequent,  or  constant,  and  yet  useless,  nothing,  or  very  little  being 
raised,  iodide  of  potassium  will  bring  on  a  secretion  of  thin  mucus,  and 
so  re-establish  a  moist  condition  of  the  membrane,  thereby  relieving  the 
irritation,  and  at  the  same  time  unload  the  vessels  and  remove  the  swell- 
ing.    Why,  then,  should  it  not  be  more  often  employed  in  this  condition  ? 


PNEUMATICS.  245 

Another  kind  of  case  in  which  it  may  be  used  may  be  named,  when 
the  tubes  are  not  dry,  but  contain  an  increased  quantity  of  mucus,  but 
that  so  tenacious  as  to  be  with  difficulty  removed,  being  brought  up  as 
"  stringy  "  phlegm  with  no  little  difficulty  ;  sometimes  it  seems  to  plug 
some  of  the  tubes.  In  these  cases  the  cough  is  troublesome,  but  ineffect- 
ual, and  whatever  will  liquefy  or  dilute  the  secretion  will  give  relief. 
Iodide  of  potassium  causes  an  extra  flow  of  thin  mucus,  and  is  also  be- 
lieved to  exercise  an  attenuant  effect  on  the  secretion  already  in  the 
tubes,  but,  whether  it  does  this  or  not,  the  extra  flow  dilutes  what  is  al- 
ready there,  and,  even  if  the  thick  phlegm  will  not  mix  with  or  dissolve 
in  the  new  watery  outflow,  it  will  at  least  float  in  it  and  be  loosened 
from  the  walls  of  the  tubes  by  it,  and  so  be  more  easily  coughed  up. 

Iodine  has  also  been  said  to  be  an  antispasmodic  expectorant,  but  if 
so,  it  would  for  the  most  part  be  by  an  indirect  influence.  Free  secretion 
of  itself  naturally  tends  to  remove  tenacious  phlegm,  or  foreign  bodies, 
as  well  as  to  relieve  engorged  vessels,  and  so  far  to  relax  spasm  set  up 
by  such  influences.  The  inhalation  of  ethyl-iodide,  however,  will  often 
rapidly  relax  the  spasm  of  asthma,  and  recently  Prof.  Germain  See  has 
employed  with  considerable  success  sprays  of  iodide  of  potassium  for  the 
same  purpose.  It  seems  to  me  probable  that  the  action  in  the  last  case 
is,  as  stated,  indirect,  but  with  regard  to  the  vapor  of  ethyl-iodide  the 
effect  is  too  rapid  to  be  thus  accounted  for. 

We  have  no  proof  that  iodine  depresses  the  respiratory  centre  ;  its 
action  on  the  mucous  membrane  is  therefore  not  to  be  referred  to  the 
nervous  system  ;  and  though  there  are  many  other  uses  for  this  remedy 
which  have  almost  overshadowed  its  expectorant  properties,  these  last 
can  scarcely  be  considered  as  the  least  valuable. 

Very  curious  differences  in  the  susceptibility  of  patients  to  the  influ- 
ence of  iodine  may  be  constantly  observed.  Some  are  so  extremely  sus- 
ceptible that  minute  doses  at  once  produce  iodism,  and  others  are  so 
easily  affected  by  it  that  it  is  extremely  disagreeable  to  them.  In  some 
this  idiosyncrasy  shows  itself  in  salivation,  in  others  in  coryza.  Some- 
times there  is  only  a  moderate  salivation,  the  fluid  being  impregnated 
with  the  taste  of  the  iodide  as  it  is  being  continually  eliminated,  so  that 
all  the  food  tastes  of  the  salt,  to  the  great  disgust  of  the  patient,  and 
the  digestion  is  apt  to  be  deranged.  To  many  persons  this  taste  is  ex- 
ceedingly repugnant.  When  the  respiratory  membrane  is  affected,  the 
patient  seems  to  catch  cold,  sneezing  being  early  followed  by  free  secre- 
tion. Occasionally  the  catarrh  is  so  easily  induced  that  we  cannot  use 
the  remedy,  but  usually  it  can  be  restrained  or  arrested.  A  dose  of 
morphia  will  generally  accomplish  this,  and  sometimes  very  small  quan- 
tities of  an  opiate  given  with  the  iodide  enable  the  patient  to  tolerate  it. 
In  mild  cases  a  single  dose  of  morphia  arrests  the  coryza,  and  prevents 
the   development   of  worse  symptoms.     The   antagonism   of   these   two 


246  THERAPEUTICS    OF   THE    RESPIRATOKY    PASSAGES. 

medicines,  so  far  as  the  mucous  membrane  is  concerned,  is  fairly  com- 
plete, but  we  must  not  forget  that  opium  affects  the  centre  and  it  is 
often  undesirable  to  give  it.  Belladonna  is  also  to  the  same  extent  an- 
tagonistic to  iodine.  Possessing  a  very  special  influence  on  the  salivary 
glands,  it  is  perhaps  preferable  where  they  are  chiefly  excited,  but  ex- 
perience satisfies  me  that  it  also  antagonizes  the  effect  of  iodides  on  the 
pituitary,  faucial,  laryngeal,  tracheal,  and  bronchial  lining.  I  have  used 
atropia  to  restrain  and  arrest  the  effects  of  the  iodides  in  these  situations 
with  great  success,  especially  where  opium  was  contra-indicated  or  un- 
desirable, but  much  more  frequently  I  rely  upon  morphia. 

There  is  an  opposite  condition  to  the  extreme  susceptibility  noticed 
above.  Some  patients  seem  almost  insusceptible  to  the  action  of  iodine  ; 
and  others,  to  whom  it  is  given  in  large  quantities  with  great  benefit  for 
various  purposes,  never  experience  any  irritation  of  the  respiratory  pas- 
sages. This  seems  to  me  specially  the  case  when  large  doses  of  iodide 
are  required.  In  syphilis  I  have  administered  very  large  doses  for  long 
periods,  and  that,  too,  when  the  fauces  and  larynx  have  been  seriously 
diseased,  without  exciting  irritation  of  the  membrane.  Such  cases  are, 
indeed,  of  daily  occurrence,  and  yet  out  of  numerous  instances  of  iodism 
I  have  met  with  few  in  syphilitics.  It  would  be  interesting  to  learn 
whether  this  is  the  general  experience. 

The  uses  of  iodine  in  respiratory  diseases  may  be  deduced  from  its 
action.  In  bronchitis  it  is  only  admissible  as  a  promoter  of  secretion  in 
the  manner  already  explained.  Where  the  expectoration  is  thin  and 
easily  coughed  up,  the  iodides  are  useless,  if  not  contra-indicated.  In 
asthma.  Trousseau  and  Jaccoud  both  found  it  useful,  and  long  before  it 
had  been  used  by  Horace  Green,  and  it  also  constituted  the  chief  ingre- 
dient of  a  once  popular  quack  remedy.  Dr.  Salter  sometimes  obtained 
benefit  from  full  doses.  Dr.  C.  J.  B.  Williams  employed  it  in  combina- 
tion w'ith  carbonate  and  stramonium  {3Ied.  Times,  187:2).  Dr.  Reed 
employed  liquor  iodi  in  constitutional  dry  asthma,  when  the  paroxysms 
came  on  without  obvious  cause  [Med.  Record,  1879),  and  during  the  last 
few  years  M.  See  has  reported  {La  France  Med.)  a  number  of  cases  at 
all  ages,  in  which  he  has  given  doses  of  twenty  to  forty-five  grains,  daily 
reducing  the  dose  as  the  improvement  continued.  Often  he  found  the 
breathing  become  easy  in  an  hour  or  two  after  such  a  dose  given  during 
the  paroxysm.  He  has  also  employed  with  great  benefit  sprays  contain- 
ing the  iodide.  There  seems  to  me  no  doubt  that  the  remedy  is  often 
very  beneficial,  especially  in  those  cases  in  which  the  paroxysms  are  ex- 
cited by  cold,  or  whenever  they  are  relieved  on  the  appearance  of  secre- 
tion. It  is  the  power  to  excite  this  secretion  that  is  probably  the  key  to 
the  use  of  the  iodide  in  asthma.  It  may  also  be  added  that  in  gouty  and 
rheumatic  patients  its  influence  is  favorable. 

So  potent  a  medicine   was  sure   to  be   tried  in   phthisis,  and  at  first 


PNE-UMATICS.  247 

there  were  not  wanting  observers  who  hoj^ed  that  a  curative  agent  had 
been  discovered,  among  whom  may  be  mentioned  Bardsley/  Gairdner,' 
Scudamore/  Clarke,*  and  others.  It  must,  however,  be  confessed  that 
disappointment  aveaited  them.  At  the  Brompton  Hospital  the  experi- 
ence of  Dr.  Cotton  {Med.  71mes,  1859)  was  not  favorable  ;  weight  was 
seldom  gained,  dyspepsia  was  often  produced,  and  a  wasting  increased. 
Others  have  observed  irritation  and  even  haemoptysis  follow  the  use  of 
this  remedy.  But  in  certain  cases  of  pneumonic  phthisis,  carefully  used 
for  a  short  time,  it  may  possibly  be  beneficial,  and  in  strumous  constitu- 
tions, where  there  is  a  fear  of  the  development  of  tubercle,  it  may  per- 
haps be  used  with  advantage,  but  any  attempt  to  produce  a  distinct  im- 
pression on  the  respiratory  organs  may  excite  local  irritation  and 
aggravate  febi'ile  excitement.  Even  the  local  use  by  inhalations  of  the 
vapor  of  iodine,  valuable  as  it  often  is,  requires  to  be  prescribed  with 
considerable  circumspection,  and  the  effect  should  always  be  watched.  It 
is  quite  possible  for  iodism  to  be  induced  by  such  inhalation.  I  have 
known  these  phenomena  brought  on  by  the  accidental  inhalation  of  the 
vapor  during  the  preparation  of  compounds  of  iodine,  as  well  as  by  the 
exposure  of  the  element  with  the  intention  of  its  becoming  evaporated 
as  a  method  of  its  administration.  It  is  in  laryngeal  phthisis  that  the 
local  effect  of  the  vapor  is  most  useful,  indeed  in  extensive  pulmonary 
disease  it  has  not  yet  accomplished  much,  and  Pereira  declared  he  had 
never  seen  it  do  any  good. 

In  pneumonia,  when  consolidation  has  continued  for  a  considerable 
period,  small  doses  of  iodide  of  potassium  will  sometimes  set  up  the  pro- 
cess of  absorption.  Some  physicians  have  employed  the  iodide  at  an 
earlier  stage.  Dr.  Gualdi  treated  thirty-nine  cases  from  the  beginning 
with  frequent  doses  of  iodide  of  potassium,  and  obtained  excellent  re- 
sults ;  two  only  died,  and  one  of  these  from  a  complication  at  the  outset. 
In  all  cases  the  expectoration  from  being  tenacious  and  viscid  became  on 
the  second  day  fluid,  resembling  bloody  serum,  the  fever  ceased  and  with 
it  the  exhaustion,  though  the  state  of  the  lungs  was  not  improved.  The 
appetite  of  the  convalescents  was  greatly  increased.  Dr.  Gualdi  found 
the  treatment   succeed  better   in  young  persons  than   adults,  and  urges 


'  Bardsley,  J.  L.  :  Hospital  Facts  and  Observations.     On  Iodine,  etc.     1830. 

■  Gairdner,  W.  :  Essay  on  the  Effects  of  Iodine  on  the  Hnman  Constitution,  witli 
Practical  Observations  on  its  Use  in  the  Cure  of  Bronchocele,  Scrofula,  and  Tuberculous 
Diseases  of  the  Chest  and  Abdomen.     1824. 

'  Scudamore,  Sir  C.  :  Cases  illustrating  the  Remedial  Power  of  the  Inhalation  of 
Iodine  and  Conium  in  Tubercular  Phthisis  and  various  Disordered  States  of  the  Lungs 
and  Air-passages.     1834. 

"•  Clarke,  Sir  A.  :  On  the  Exhibition  of  Iodine  in  Tubercular  Consumption  and  other 
Diseases  of  the  Chest,  and  in  the  Treatment  of  Scrofulous,  Cancerous,  and  Cutaneous 
Diseases,  etc,     1845. 


248  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

that  the  remedy  should  be  given  at  the  commencement  of  the  disease. 
In  croup  and  diphtheria  the  iodides  have  been  employed  with  a  view  of 
separating  the  false  membrane  by  causing  a  profuse  flow  of  watery  se- 
cretion. 

Iodoform  differs  so  much  from  the  other  preparations  as  to  require  a 
few  words  to  itself.  It  does  not  seem  to  irritate  the  mucous  membranes 
like  the  other  preparations,  so  that  iodism  very  seldom  follows  its  use, 
and  it  is  well  tolerated  by  the  stomach.  It  is  rapidly  absorbed.  Hogyes ' 
says  the  first  step  is  its  solution  in  such  fatty  matter  as  it  may  meet  with, 
this  solution  being  in  turn  decomposed  by  albumen,  as  a  compound  of 
which  it  enters  the  blood.  The  iodine  is  eliminated  in  combination  with 
sodium  in  the  same  manner  as  when  taken  in  other  forms,  but  some 
iodoform  seems  to  escape  from  the  skin,  or  in  the  breath,  for  a  person 
who  has  taken  it  for  some  time  evolves  the  characteristic  odor.  Con- 
sidering its  chemical  relations  with  chloroform  it  was  conjectured  that  it 
might  be  anaesthetic,  and  locally  it  seems  to  possess  this  property.  Maitre 
pointed  out  {^Bouchardaff s  Annales,  1857)  that  its  application  relieved 
pain,  and  examined  its  action  on  the  nervous  system,  respecting  which 
experimenters  are  not  agreed.  He  compared  it  to  alcohol,  and  in  some 
instances  it  seems  to  narcotize,  as  shown  by  McKendrick  [Edin.  Med. 
Journ.,  1874)  and  again  by  Hogyes  {3Ied.  Record,  1879).  I  have  em- 
ployed it  largely  internally,  though  not  as  an  expectorant,  and  the  effect 
on  the  mucous  membrane  seems  but  slight,  yet  the  other  medicinal  effects 
of  iodine  may  be  obtained  from  this  preparation.  I  compared  it  with 
others  in  a  paper  read  at  the  Medical  Society  of  London,  in  1871  {Med- 
ical Press,  1871-72),  and  have  continued  to  use  it  largely  ever  since 
{Brit.  Med.  Jour.,  1878).  Of  late  it  has  been  employed  with  a  view  to 
an  antiseptic  action,  especially  in  Italy.''  Dr.  Dreschfeld  introduced  it 
into  this  country  in  1882,  as  likely  to  be  of  service  in  phthisis,  and  Dr. 
A.  Ransome  read  a  paper  on  it  at  the  British  Medical  Association,  in 
1883.  He  gave  it  in  doses  of  1^  grain  three  times  a  day,  and  found 
that  it  disturbed  the  digestion,  whereupon,  on  the  suggestion  of  Dr. 
March,  he  added  two  grains  of  croton-chloral-hydrate.  He  used  at  the 
same  time  inhalations  and  had  the  patients  weighed  before  and  after 
treatment.  He  attributes  to  iodoform  "  some  slight  improvement,  even 
in  cases  in  which  it  was  manifestly  hopeless  to  expect  a  cure,"  and 
thinks  that  "  in  the  earlier  stages  of  the  disease,  it  is  decidedly  worthy 
of  further  trial."  I  have  very  seldom  found  such  doses  interfere  with 
digestion,  I  have  often  given  three  grains  three  times  a  day  for  weeks  to- 
gether without  the  slightest  inconvenience.  A  combination  with  an 
equal    quantity  of    storax    greatly  controls  the  disagreeable  odor  ;  but 

'  Hogyes  ;  Archiv  f.  exper.  Path,  und  Pharm. 

-Lo  Sperimeutale,  1883,  and  Anuali  Univers.  di  Med.  e  Chir.,  1883. 


PNEUMATICS.  249 

when  the  system  becomes  saturated,  so  to  say,  with  the  medicine,  tiie 
patient  begins  to  feel  the  inconvenience  of  continually  perceiving  the 
smell. 

Antiseptic  and  Disinfectant  Pneumatics. 

We  have  already  had  occasion  to  speak  of  antiseptics,  when  treating 
of  antipyretics,  and  perhaps  it  would  be  as  well  to  recur  to  the  subject 
here,  inasmuch  as  the  pneumatics  of  which  we  are  about  to  speak  are 
such  as  are  supposed  to  act  through  the  system.  The  idea  of  disinfec- 
tion is  by  no  means  modern.  Homer  speaks  of  sulphur  as  a  disinfect- 
ant, and  the  preservative  power  of  salt  and  of  vinegar  was  known  at  an 
early  age.  Even  the  word  antiseptic  is  by  no  means  so  modern  as  some 
have  supposed,  and  it  was  preceded  by  antiloimic  (avrt,  and  Xoi/aos, 
pestilence),  a  term  which  was  applied  to  any  substance  supposed  to  pre- 
vent infection  from  the  plague  or  other  pestilence.  We  have  seen  that 
Pringle  '  used  the  word  antiseptic  in  the  title  of  his  paper,  and  he  was 
soon  followed  by  MacBride.^  In  1767  the  Dijon  Academy  of  Science 
offered  a  prize  for  an  essay  on  antiseptics,  and  two  years  afterward  three 
of  the  essays  '  submitted  were  publislied. 

The  same  year  Godwin  *  produced  his  "  Septicologie,"  and  soon  after 
Alexander,^  Brownrigg,"  and  Henry  '  published  English  essays  on  the 
subject.  Cartheuser  *  and  Callisen"  followed  in  Latin,  Bucholz  '"  in  Ger- 
man, and  a  little  later  Mugis  "  and  Grewe  '^  in  Latin.  Nearly  fifty  years 
then  elapsed  before  Kaiser'^  published  his  experiments  on  the  compara- 
tive antiseptic  power  of  several  agents.  Nearly  forty  years  more  before 
Lister  began  what  may  be  considered  the  modern  antiseptic  system 
in  surgery,  for  an  exposition  of  which  we  must  refer  to  his  contributions 


'  Pringle,  J.  :    Op.  cit. 

^  MacBride,  D.  :  Experimental  Essays.    1764. 

'  Boisseau,  B.  C. ,  Bordenave,  S.,  et  Godart,  J.  :  Dissertations  sur  les  Antiseptiques, 
qui  concoururent  pour  le  Prix  propose  par  I'Academie  des  Sciences  de  Dijon  en  1767- 
1769. 

*  Godwin,  J.  :  Septicologie,  ou  Dissertation  sur  les  Antiseptiques.     17G9. 

'Alexander,  W.  Experimental  Essays :  On  Antiseptics,  etc.,  1770. 

^Brownrigg,  W.  :  On  the  Means  of  Preventing  the  Communication  of  Pestilential 
Contagion,  and  of  Eradicating  it  in  Infected  Places.     1771. 

'  Henry,  S.  :   On  Antiseptic  Substances.     1773. 

^Cartheuser,  J.  F.:  De  remediis  Antisepticis.     1774. 

8  Callisen,  H.  :  De  Antisepticis.     1775. 

'"  Bucholz,  C.  F.  :  Chym  Versuche  iiber  einige  der  neuesten  einheimischen  antisep- 
tichen  Substanzen.     1776. 

"  Mugis,  P.  N. :   De  antisepticis  proprie  dictis.     1781. 

"  Grewe,  T.  :  De  putridine  et  Antisepticis.     1782. 

'^  Kaiser,  J.  :  Experimenta  ad  Comparandam  vim  Antisepticam  Aceti,  Nitri,  Salis 
communis,  et  Chloreti  calcis  instituta.     1831. 


250  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

and  those  of  his  followers  in  the  various  journals  since  18G9.  Dr.  San- 
som's  '  able  treatise  refers  to  the  medical  as  well  as  t-he  surgical  uses  of 
antiseptics. 

In  diseases  of  the  respiratory  organs  we  may  select  a  remedy  which 
is  believed  to  possess  antiseptic  powers  fortwo  purposes  :  first,  tliat  when 
it  is  excreted  through  the  bronchial  membrane  it  may  disinfect  the 
sputa  ;  second,  in  the  hope  that  it  may  prove  destructive  to  the  organ- 
isms supposed  to  be  present  in  the  body.  With  regard  to  the  first  indi- 
cation, we  have  seen  that  a  number  of  expectorants  may  act  in  this  man- 
ner, but  the  use  of  antiseptic  inhalations  would  seem  to  be  more 
eflScacious.  As  to  the  second  point,  the  whole  theory  of  the  parasitic 
origin  of  disease  is  involved.  This  theory  is  undoubtedly  a  fascinating 
one,  admitting  the  presence  of  an  organism  to  be  the  cause  of  a  disease, 
the  business  of  the  therapeutist  would  be  to  search  for  a  remedy  which 
would  be  poisonous  to  the  parasite  but  not  to  the  patient.  In  quinine, 
as  we  have  seen,  these  requisites  appear  to  meet.  Minute  quantities  are 
fatal  to  whole  colonies  of  putrefactive  organisms,  and  very  large  quanti- 
ties can  be  taken  into  the  human  body,  and  will  linger  in  the  system  for 
a  considerable  period.  If,  therefore,  a  disease  be  caused  by  an  organism 
to  which  quinine  is  fatal,  its  administration  will  effect  a  cure,  provided 
no  irreparable  injury  has  been  inflicted.  It  is  believed  by  many  that  the 
virtues  of  quinine  really  depend  on  this  property.  Unfortunately  it  is 
powerless  over  some  other  organisms,  and  we  have  to  search  for  more 
potent  poisons. 

Buchner  denies  the  value  of  antiseptic  treatment,  and  seems  to  think 
that  it  is  impossible  to  satisfactorily  carry  it  out,  at  any  rate  with  the 
agents  now  at  our  disposal.  Koch  has  shown  that  corrosive  sublimate  is 
fatal  to  the  bacteria  of  anthrax  in  the  proportion  of  one  part  to  two  hun- 
dred thousand.  To  reach  this  proportion  in  the  mass  of  a  man's  blood 
would  require  doses  of  two-fifths  of  a  grain.  Such  proportionate  doses 
have  been  injected  into  the  veins  of  animals  by  Binz,  without  killing 
them,  and  he  seems  to  think  that  it  would  not  be  impossible  to  employ 
this  remedy  in  man,  but  Buchner  [Centralb.  f.  Jclhi.  3Iecl.,  1883)  re- 
marks that  the  sublimate  combines  with  the  all)umen  of  the  blood,  and 
that  the  resultant  albuminate,  thougli  remaining  in  solution,  is  less  dif- 
fusible, less  capable  of  osmosis,  and  therefore  less  likely  to  be  equally 
distributed  through  the  tissues,  while  it  is  at  the  same  time  less  poison- 
ous. He  found  double  the  quantity  of  albuminate  of  mercury  to  that  of 
the  sublimate  was  required  to  destroy  the  bacteria,  and  he  calculates 
that  for  quinine  to  act  as  an   antiseptic  it  would  have  to   be  given  in 

*  Sansoin,  A.  E.  :  The  Antiseptic  System :  A  Treatise  on  Carbolic  Acid  and  its 
Compounds.  A  Theory  and  Practice  of  Disinfection,  and  the  Practical  Application  of 
Antiseptics,  especially  in  Medicine  and  Surgery.     1871. 


PNEUMATICS.  251 

three-ounce  doses,  but  he  admits  that  there  is  probably  some  relation  be- 
tween the  value  of  a  remedy  in  disease  and  its  power  of  destroying 
micro-organisms  outside  the  body,  but  what  that  relation  is  remains  to 
be  proved. 

Different  micro-organisms  vary  greatly  in  the  effects  they  produce, 
and  it  has  been  stated  rather  confidently  that  perfectly  healthy  tissues 
harbor  germs.  The  recent  researches  of  Hauser  and  Zahn  discounte- 
nance this  idea.  Hauser  {Centralb.  f.  die  3Ied.-Wissensch.,  1884)  re- 
moved entire  organs  and  parts  of  tissues  by  heated  instruments  from 
animals  just  killed  to^  super-heated  glass  vessels,  plugging  the  mouths 
with  cotton-wool.  He  kept  the  vessels  in  a  moist  chamber,  at  a  temper- 
ature of  30°  C.  Zahn  (  Yirchoid^s  Archives,  1884)  employed  the  blood 
of  healthy  animals,  collecting  it  with  full  precautions  in  tubes  previously 
filled  with  oxygen,  hydrogen,  and  carbonic  acid,  so  as  to  exclude  atmo- 
spheric air.  The  tubes  were  kept  sealed  at  a  temperature  of  37°  to  38° 
C.  for  months  without  any  sign  of  putrefaction. 

We  have  seen  that  some  organisms  are  destroyed  by  quinine.  Kru- 
kenberg'  found  some  which  were  killed  by  one  in  one  hundred  thou- 
sand. Others,  however,  require  one  in  twenty  thousand,  and  others  may 
resist  a  stronger  solution.  Then  we  must  remember  that  what  one  para- 
siticide fails  to  effect  may  be  accomplished  by  another,  and  so  when 
organisms  resist  one  influence,  we  must  seek  for  something  that  will  be 
noxious  to  them.  Perhaps  the  bacterium  subtile  is  the  most  difficult  to 
destroy.  It  will  resist  boiling  for  an  hour.  Yet  M.  Schnetzler  has  this 
year  reported  to  the  Paris  Academy  that  it  is  easily  killed  by  formic  acid. 
To  a  drop  of  water  teeming  with  these  bacteria  he  adds  a  drop  of  liquid 
containing  one-thousandth  part  of  formic  acid,  and  says  that  the  effect  is 
such  that  the  liquid  may  be  introduced  into  the  digestive  tract  with  im- 
punity. If  this  be  confirmed,  the  fact  may  probably  be  turned  to  practi- 
cal account  in  preventing,  if  not  in  curing,  disease.  Experiments  with 
tubercular  sputa  seem  to  show  that  it  possesses  great  power  of  resistance 
to  our  ordinary  antiseptics.  Falk  announced  that  its  virulence  was  de- 
stroyed by  putrefaction,  but  this  has  not  been  confirmed,  and  the  bacilli 
have  been  found  in  putrefying  sputa.  Baumgarten  thought  the  viru- 
lence of  tubercular  material  was  diminished  by  putrefaction.  Parrot  and 
Martin  {Eev.  de  Med.,  1883)  found  that  the  infective  power  was  not  de- 
stroyed by  corrosive  sublimate  solution  of  one  in  one  thousand  ;  bro- 
mine, one  in  one  thousand  ;  salicylic  acid,  one  in  five  hundred  ;  carbolic 
acid,  one  in  twenty.  But  a  temperature  of  100°  to  120°  C.  was  sufficient. 
Recently  Dr.  Niepel  {La  France  Med.,  1884)  has  stated  that  sulphuretted 
hydrogen  destroys  the  infective  property.  Professor  J.  Sormani,  of 
Pavia,  brought  before  the  late  Hygienic  Congress  at  the  Hague  (August, 

'  Krukenberg  :  Vergleicliemd.  riij'siologische  Studien.     1880. 


252  THERAPEUTICS    OF   THE    RESPIRATORY   PASSAGES. 

1884),  the  results  of  numerous  experiments  as  to  the  possibility  of  de- 
stroying the  tubercle  bacillus.  The  following  are  his  conclusions  :  1. 
The  bacilli  of  tuberculosis  were  generally  very  diflficult  to  destroy  ;  dry- 
ness, exposure  to  oxygen,  putrefaction,  and  most  disinfectants  failed  to 
produce  any  effect.  2.  A  temperature  of  100°  0.  only  killed  the  bacilli 
after  at  least  five  minutes  of  ebullition.  3.  The  artificial  digestion  of 
bacilli  showed  that  they  were  the  last  of  all  living  organisms  to  be  de- 
stroyed by  the  gastric  juices  or  hydrochloric  acid.  A  very  active  digest- 
ion is  necessary  to  kill  this  microbe.  A  healthy  man  may  destroy  the 
bacilli  in  his  stomach,  but  an  infant  or  an  adult  with  his  digestive  facul- 
ties impaired  would  easily  allow  the  germ  to  pass  the  stomach  intact, 
and  retain  its  virulence  in  the  intestinal  tube.  This  determined  enteric 
ulcerations,  etc.  4.  The  bacillus  of  tuberculosis  can  be  preserved  intact 
for  a  whole  year  when  mixed  with  water.  It  is  probable,  though  not 
proved,  that  it  has  retained  its  virulence  during  that  time.  Thus  drink- 
ing-water may  become  the  means  of  propagating  tuberculosis.  It  is 
probable  that  contaminated  linen  retains  its  virulence  for  five  or  six 
months.  5.  Alcohol  does  not  destroy  the  germ  ;  hard  drinkers  often 
suffer  from  tuberculosis.  G.  Cod-liver  oil,  ozone,  oxygenated  preparations, 
and  other  similar  remedies,  have  no  effect  in  killing  the  bacillus,  nor  are 
benzoate  of  soda,  salicylate  of  soda,  sulphate  of  zinc  and  carbolic  acid, 
iodide  of  silver,  bromide,  camphor,  etc.,  of  much  greater  use.  They  in- 
jure, perhaps,  but  do  not  absolutely  destroy  the  bacillus,  at  least  not  in 
the  doses  that  can  be  taken  without  danger.  7.  A  more  decisive  action 
may  be  attributed  to  creasote,  eucalyptol,  pure  carbolic  acid,  the  naph- 
thols,  and  bichloride  of  mercury.  8.  For  disinfecting  spittoons,  a  car- 
bolic acid  solution  of  five  per  cent,  is  thought  sufficient,  and  Dr.  Sor- 
mani  asserts  that  the  breath  never  contains  any  bacillus.  He  also 
suggested  that  oil  of  turpentine  or  eucalyptus  should  be  diffused  in 
liouses  as  an  agent  for  the  destruction  of  this  bacillus. 

Although  it  may  seem  that  if  we  could  saturate  the  system  with- 
out inconvenience  with  a  substance  fatal  to  microbes,  we  should  thus 
be  able  to  effect  an  immediate  cure  of  diseases  dependent  upon  them,  it 
does  not  necessarily  follow  that  less  active  parasiticides  are  useless.  It  is 
easy  to  imagine  that  a  small  quantity  of  an  antiseptic,  though  insufficient 
to  kill,  may  cause  inconvenience  to  parasites,  especially  if  such  antiseptic 
should  be  excreted  through  an  organ  in  which  they  have  effected  a 
lodgement.  Moreover,  it  may  well  be  that  such  an  antiseptic  might  im- 
prove the  condition  of  that  organ,  and  thereby  render  it  a  less  suitable 
nidus  for  the  microbe.  And  again,  it  is  possible  that  a  substance  in  the 
process  of  elimination  from  the  body,  either  by  decomposition  or  other- 
wise, may  be  more  noxious  to  micro-organisms  than  when  employed  in 
a  culture-fluid.  The  conditions,  in  fact,  in  the  living  body  differ  greatly 
from  those  in  the  laboratory,  otherwise  we  should  only  have   to   collect 


PNEUMATICS.  258 

the  organisms  and  destroy  them.  It  must,  too,  be  freely  admitted  that 
the  reactions  of  the  system,  provoked  by  the  parasites,  form  no  incon- 
siderable proportion  of  the  phenomenon.  Nevertheless,  they  scarcely 
account  for  the  whole,  and  while  freely  admitting  all  that  is  to  be  said 
in  favor  of  the  nervous  theory,  we  are  scarcely  in  a  position  to  deny  the 
reasonableness  of  the  antizymotic  explanation. 

Antiseptic  pneumatics  belong  to  several  groups.  Some  of  them  have 
an  expectorant  action  and  may  be  called  properly  enough  antiseptic  ex- 
pectorants. But  there  are  others  of  which  the  modus  operandi  is  not  so 
clear,  and  there  are  some  general  antiseptics  which  are  useful  in  respira- 
torv  diseases,  but  are  not  expectorant  at  all,  and  perliaps  possess  even 
opposite  properties,  e.g.,  tonic  antiseptics,  such  as  quinia,  etc.  That 
the  antiseptic  or  disinfectant  action  is  exercised  on  the  sjjuta  is  reason- 
able enouo-h  to  suppose  when  the  remedy  is  excreted  by  the  bronchial 
mucous  membrane,  and  we  have  seen  that  several  such  true  expectorants 
are  calculated  to  act  in  this  manner,  but  there  is  no  doubt  also  an  action 
on  the  mucous  membrane  itself.  Thus  an  alterative  expectorant  may  be 
antiseptic  and  quite  a  number  of  stimulant  expectorants  are  antiseptics, 
such  as  essential  oils,  the  balsams,  the  camphors,  and  the  turpenes.  Eu- 
calyptus, which  has  been  lately  so  much  employed,  may  be  classed  among 
these.  Cubeb  contains  an  essential  oil,  and  as  this  is  perhaps  eliminated 
partlv  bv  the  bronchial  membrane,  it  would  seem  more  adapted  for  dis- 
eases of  this  tissue  than  the  crude  piper.  But  the  value  of  this  medicine 
has  been  much  exaggerated  of  late  years.  Other  essential  oils  are  nicer 
and  better. 

Tar  and  its  derivatives  may  be  mentioned  here,  though  in  the  pres- 
ent day  thevare  more  used  as  local  antiseptics.  Tar  is  the  iriTTa  of  Theo- 
phrastus,  the  kcovos  or  TrtWa  vypa.  of  Dioscorides,  t\\Q  pix  liquida  of  Pliny. 
In  the  middle  of  the  last  century  it  was  suddenly  brought  into  vogue  by 
Bishop  Berkeley,'  the  great  philosopher,  who  seems  to  have  thought  that 
he  had  discovered  a  panacea  in  tar-water,  and  whose  book  on  the  subject 
gave  rise  to  a  great  number  of  pamphlets  for  and  against  the  use  of  the 
remedy,  one  of  them  quaintly  entitled  "  Cure  for  the  Epidemical  Madness 
of  Drinking  Tar-water."  Nevertheless  the  good  bishop  and  learned  phi- 
losopher returned  to  the  charge,  professed  unbounded  belief  in  his  pana- 
cea, and  no  doubt  thought  that  he  was  serving  his  fellow-creatures  in 
making  known  his  favorite  remedy.  It  soon,  however,  fell  into  disuse, 
though  it  has  at  times  been  revived.  It  is  still  occasionally  prescribed  in 
catarrhal  affections  and  in  phthisis,  and  indeed  of  late  years  an  attempt 
has  been  made  to   introduce  special   preparations   of  tar  into  use.     Dr. 

'  Berkeley,  G.  (Bishop  of  Cloyne) :  Siris :  A  Chain  of  Philosophical  Reflections  and 
Inquiries  respecting  the  Virtues  of  Tar  Water,  etc.  1744.  Also,  Two  Letters  on  the 
Usefulness  of  Tar  Water  in  the  Plague.  1747.  Also,  Further  Thoughts  on  Tar  Water. 
1752. 


254  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

Dunglison  '  reported  considerable  benefit  in  clironie  bronchitis  ;  he  di- 
rected one  ounce  of  tar  to  be  digested  in  two  pints  of  water  for  a  week 
and  strained  ;  of  this  he  gave  from  eight  to  twelve  ounces  daily  mixed 
with  milk.  The  inhalation  of  tar  vapors  is  more  rational  and  often  of 
service. 

The  discovery  of  Creasotc  by  Reichenbach,"  who  named  it  from  Kpeas, 
flesh,  and  o-w^o),  I  preserve,  led  to  the  disuse  of  the  crude  remedy  and 
the  substitution  of  the  supposed  active  principle,  both  for  internal  use 
and  for  inhalations.  It  seems,  however,  that  creasote  is  not  a  simple 
body  but  a  rather  valuable  compound  containing  a  good  deal  of  creasol, 
and  there  is  little  doubt  that  very  impure  preparations  have  found  their 
way  into  the  market. 

As  tar  was  displaced  by  creasote  so  this  in  its  turn  has  been  largely 
superseded  by  carbolic  acid  and  its  compounds,  as  have  also  some  old 
preparations  of  soot,  pyroligneous  acid,  rag  oil,  paper  oil,  animal  oil, 
mummy,  and  other  obsolete  medicaments.  Creasote,  liowever,  has  been 
largely  employed  internally,  and  EUiotson,'  Miquet,*  and  Sir  John  Cor- 
mack  ^  have  written  in  its  favor,  while  it  still  maintains  a  place  as  a  valu- 
able inhalation.  Carbolic  acid,  though  chiefly  obtaitied  from  coal-tar,  is 
produced  in  small  quantities  during  the  distillation  of  benzoin  and  some 
other  gum-resins,  and  is  also  said  to  be  found  in  the  urine  of  man,  and 
some  animals.  In  the  Italian  war  of  liberation,  in  1859,  some  of  the 
French  surgeons  used  a  powder  containing  coal  tar  and  lime  as  an  appli- 
cation to  wounds.  In  18G3  Dr.  Lemaire  discussed  Pasteur's  germ  theory, 
in  a  volume  on  carbolic  acid.°  He  had  previously  published  a  work  on 
coal-tar.'  He  recommended  the  new  product  as  an  antiseptic  application 
in  wounds,  injuries,  and  diseases,  and  advised  its  internal  use  in  diseases 
due  to  infective  poisons.  A  couple  of  j-ears  later,  M.  Boboeuf  *  addressed 
the  Academy  of  Paris  on  the  value  of  phenol  and  the  history  of  its  use. 

'  Dunglison :  Practice  of  Medicine.     1844. 

'  Reichenbach,  C.  von.  :  Das  Kreosot,  in  chemischer,  physischer,  und  medicinischer 
Beziehung,  etc.     1833. 

3  EUiotson,  J.  :  Med.  Cliir.  Trans.     1835. 

*  Miquet,  E.  :  Recherches  cliimiqnes  et  medicales  de  creosote.     1834. 

*  Cormack,  J.  Rose :  A  Treatise  on  the  Chemical,  Medical,  and  Physiological  Prop- 
erties of  Creosote,  illustrated  by  Experiments  on  the  Lower  Animals,  etc.  Harveian 
Prize.     1836. 

^  Lemaire,  J.  :  De  I'Acide  Pheniq\ie,  de  son  action  sur  les  vegetaiix,  les  animaux, 
les  ferments,  les  renins,  les  virus,  les  miasmes,  et  de  ses  applications  a  Thygiene,  etc. 
1863. 

■'  Lemaire,  J.  :  Du  coal-tar  saponifie,  disinfectant  energique  arretant  les  fermen- 
tations ;  de  ses  applications  a  I'hygiene,  a  la  therapeutique,  a  I'histoire  naturelle. 
1860. 

**  Boboeuf,  P.  A.  F.  :  Memoire  adresse  a  TAcad.  des  Sciences  sur  I'acide  Phenique, 
etc.  ;  Proprietc  s  du  Phenol  Sodique,  etc.     1865. 


PNEUMATICS.  255 

About  the  same  time  M.  Declat  '  wrote  on  the  subject  and  he  has  since 
contributed  a  number  of  papers  respecting- it.  In  England,  Dr.  Turner,  of 
Manchester,  communicated  a  paper  to  the  British  Association  in  18G3,  in 
which  he  recommended  carbolic  acid  as  antiseptic  and  astringent  in  mu- 
cous discharges,  etc.  Dr.  Grace  Calvert  about  this  time  took  up  the 
study  of  the  acid  as  a  disinfectant.  In  1867,  Lister  began  that  system- 
atic use  of  antiseptic  dressings  which  has  been  so  fully  developed. 

ANTisrASMODic    Pnkumatics. 

The  ancients  were  well  acquainted  with  a  number  of  our  antispas- 
modics and  formed  a  tolerably  clear  estimate  of  their  virtues.  Early  in 
the  last  century  Bauer  ^  turned  Ins  attention  to  the  general  antispasmod- 
ics, and  soon  after  the  middle  the  Dijon  Academy  awarded  a  prize  to 
Godart  ^  for  an  essay  on  the  subject,  and  perhaps  to  the  interest  thus  ex- 
cited we  owe  Nonne's  *  work,  which  appeared  soon  after.  At  the  begin- 
ning of  this  century  a  brief  account  of  antispasmodics  was  published  by 
Sproede/  and  nearly  thirty  3'^ears  later  a  short  treatise  by  Salinger."  Of 
course,  during  this  period,  as  previously,  these  medicines  continued  to  be 
largely  employed.  The  word  was  applied  in  a  wide  sense  and  many 
remedies  were  included  in  it  which  we  now  classify  in  a  different  manner. 

Tliose  antispasmodics  which  are  employed  in  respiratory  diseases, 
whether  alone  or  in  combination  with  pneumatics,  furnish  an  interesting 
and  important  group,  and  although  they  might  be  otherwise  classed, 
bringing  them  together  under  this  head  affords  an  opportunity  of  com- 
paring their  actions  with  advantage.  In  considering  expectorants  we 
have  seen  that  many  of  them  possess  antispasmodic  properties.  They 
may  therefore  be  called,  as  indeed  they  frequently  are,  antispasmodic  ex- 
pectorants. On  the  other  hand,  some  antispasmodics,  though  given  in  re- 
spiratory diseases,  are  not  expectorant  at  all,  but  restrain  rather  than  pro- 
mote the  secretion  of  the  bronchial  membrane.  It  is  therefore  better  to 
use  the  word  pneumatics,  in  grouping  them,  rather  than  expectorant,  which 
has  too  often  been  erroneously  applied. 

Whatever  produces  relaxation  of  muscular  fibre  may  seem  to  be  en- 
titled to  the  name  antispasmodic,  whether  the  action  be  local  or  general. 
The  inhalation  of  steam,  therefore,  might  be  included,  or  the  use  of  vapor 
baths,  or  other  baths,  or  any  method   of  applying  heat  ;  but   at  present 

'  Declat,  G.  :  Nouvelles  applications  de  I'acide  phenique  en  medicine  et  en  ch.irur- 
gie  aux  affections  occasionni'es  par  les  micropliytes,  les  microzoaires,  etc.     1865. 
'  Bauer,  C.  H.  :  De  specificis  antispasmodlcis.     1704. 
^  Godart,  G.  L.  :  Sur  les  Antispasmodiques  proprement  dits.     1765. 

*  Nonne,  J.  P.  :  De  Antispasmodicorum  modo  agendi  et  usii.     1769. 
^  Sproede,  J.  G.  L.  :  De  medicamentis  antispasmodicis.     1800. 

*  Salinger,  L.  :  De  Antispasmodicorum  differentia.     1829. 


256  THERAPEUTICS    OF   THE    RESPIRATORY   PASSAGES. 

we  are  rather  concerned  with  those  remedies  which  when  introduced  into 
the  system  produce  their  effect.  Among  the  expectorants  which  are  also 
antispasmodic,  we  have  seen  that  emetics  and  the  nauseants  possess  this 
property  in  a  high  degree  ;  though  they  are  not  often  used  on  this 
account.  As  the  act  of  vomiting  produces  intense  muscular  relaxation, 
it  may  sometimes  be  provoked  for  this  purpose  when  the  need  is  urgent. 
The  sensation  of  nausea  is  also  attended  by  relaxation,  so  that  the  nause- 
ants are  antispasmodic,  but  the  influence  in  this  case  takes  more  time  to 
produce  and  generally  lasts  longer.  The  antesthetics,  which  are  very 
powerful  antispasmodics,  have  largely  superseded  the  use  of  nauseants 
for  the  purpose  of  relaxing  muscles. 

The  majority  of  our  group  of  stimulant  expectorants  are  to  some  ex- 
tent antispasmodic,  tluis  the  essential  oils,  the  oleo-resins,  and  the  gum- 
resins  may  be  so  termed.  Assafoetida,  galbanum,  and  other  odoriferous 
remedies  have  been  known  from  very  early  times  to  possess  the  properties 
we  call  antispasmodic,  and  their  effect  on  the  bronchial  membrane  has 
already  been  explained.  Directly  opposed  to  these  are  some  of  the  de- 
pressant expectorants,  of  which  lobelia  and  tobacco  are  examples.  They 
have  both  been  used  to  relax  spasm,  though  neither  perhaps  is  entitled 
to  much  confidence,  and  should  only  be  used  with  caution.  Next  come 
a  number  of  neurotics  which  have  been  considered  antispasmodic  :  opium, 
belladonna,  hyoscyamus,  stramonium,  datura,  etc.,  are  used  as  antispas- 
modic-pneumatics.  Their  special  uses  depend  chiefly  upon  their  action 
on  the  nervous  system  ;  conium  acts  chiefly  on  the  motor  nerves.  Then 
we  have  seen  that  nitrate  of  potash  and  iodide  may  sometimes  serve  as 
antispasmodics,  and  so  indirectly  may  anything  which  causes  a  free  se- 
cretion of  mucus  and  so  relieves  the  vessels,  the  effect  being  to  remove 
the  cause  of  the  spasm.  Ipecacuanha  and  senega  sometimes  effect  this. 
All  depressants  of  the  respiratory  centre  may  serve  as  antispasmodics. 
Opium  takes  a  chief  place  here,  though  it  also  acts  over  a  more  extended 
area  ;  so  alcohol,  ether,  and  chloroform  depress  this  centre  and  under  cer- 
tain circumstances  are  antispasmodic  pneumatics,  though  we  can  obtain 
from  them  the  stimulant  action,  giving  them  only  in  small  quantities. 
The  bromides  also  depress  the  centre,  and  when  the  system  becomes  af- 
fected by  them  have  considerable  power  over  spasm.  This  is  well  seen 
in  some  cases  of  asthma  and  of  laryngismus.  Chloral,  again,  is  a  depress- 
ant of  the  centre  which  may  also  produce  similar  effect.  Then  we  have 
other  nerve-depressants,  which  become  antispasmodic  by  an  action  on  the 
nervo-muscular  apparatus  rather  than  on  the  centre.  It  will  thus  be  seen 
that  the  antispasmodic  pneumatics  differ  greatly  among  each  other.  A 
few  words  may  be  added  respecting  one  or  two  members  of  the  group, 
which  have  not  been  previously  considered. 

Amyl  nitrite,  CjH,,NO„  is  mostly  used  as  an  inhalation,  being  only 
.seldom  given  internally  ;  but  we  may  employ  it  so  in  doses  of  one-half  a 


PNEUMATICS.  257 

minim  to  one  minim.  Discovered  by  Balard  in  1844  {Annales  de  CJiimie 
et  de  Phys.  xii.),  the  attention  of  physiologists  was  directed  to  it  by 
Guthrie  in  1859,  and  in  1865  Dr.  B.  W.  Richardson  reported  on  its  physi- 
ological action  to  the  British  Association  for  the  Advancement  of  Science. 
Dr.  Lauder  Brunton  then  took  up  the  subject,  and  in  18G7  suggested  to 
the  Clinical  Society  the  use  of  amyl  in  angina  pectoris,  basing  his  rec- 
ommendation on  its  physiological  properties.  This  valuable  deduction 
has  been  fully  coJifirmed  by  clinical  experience,  and  affords  us  a  brilliant 
illustration  of  the  success  of  theory  applied  to  therapeutics.  In  1868  Dr. 
Arthur  Gamgee  communicated  to  the  Royal  Society  the  result  of  an  elab- 
orate investigation  into  the  effect  of  the  nitrite  on  the  blood  ("Philosoph- 
ical Trans.,"  1868).  In  1871  the  Warren  Prize  was  awarded  to  Dr.  H. 
C.  Wood  for  his  memoir  on  the  subject,  which  was  published  the  same 
year  {American  Journ.  Med.  Sciences,  1871). 

Amyl  nitrite  is  remarkable  for  the  rapidity  of  its  effect  on  the  circu- 
lation. A  short  inhalation  will  bring  on  immediately  palpitation  with 
fulness  and  throbbing  of  the  head,  flushing  of  the  face  and  neck,  quickly 
extending  to  the  trunk,  tingling  of  the  surface,  and  perhaps  giddiness. 
Another  inspiration  or  two,  and  j^ulsation  of  the  carotids  with  great  rest- 
lessness, disturbance  of  vision,  depression,  and  cold  sweats  follow,  with 
generally  cold  extremities,  headache,  and  some  confusion,  but  no  loss  of 
consciousness.  It  will  be  seen  that  the  chief  effect  is  on  the  circulation, 
two  very  distinct  actions  being  observed  ;  one  acceleration  of  the  cardiac 
beat,  the  other  dilatation  of  the  peripheral  vessels.  The  pulse  is  immedi- 
ately increased  in  frequency,  and  the  blood-pressure  is  simultaneously 
greatly  diminished.  Different  explanations  have  been  offered  of  these 
remarkable  effects,  but  the  great  point  is  the  sudden  fall  of  blood-press- 
ure, so  that  the  resistance  to  the  left  ventricle  is  taken  off,  its  contrac- 
tions being  more  frequent,  though  they  can  scarcely  be  more  powerful  ; 
thus  the  heart  has  less  work  to  do  and  there  is  more  power  to  do  it — that 
is  to  say,  in  a  given  time  the  number  of  contractions  is  increased.  The 
vascular  relaxation  has  been  referred  to  an  actioi\  on  the  vaso-motor 
nerves  and  muscular  coat  of  the  arterioles,  or,  on  the  other  hand,  to  an 
effect  on  the  centre  in  the  medulla.  It  really  appears  to  be  peripheral, 
not  central,  for  both  Brunton  and  Wood  found  that  it  occurred  after  the 
vessels  had  been  separated  from  the  centres  by  section  of  the  cord,  show- 
ing that  the  sudden  fall  is  produced  by  a  direct  paralyzing  action  of  the 
remedy  exercised  upon  the  coats  of  the  arterioles.  The  local  action  of 
amyl  upon  muscular  tissue  confirms  this  view.  The  quick  beat  may  per- 
liaps  be  partly  due  to  depression  of  the  cardiac  centre  or  of  the  peripheral 
cardiac  vagus. 

The  nitrite,  however  exhibited,  greatly  reduces  the  temperature,  both 
in  health  and  in  a  febrile  condition  ;  this  effect  seems  to  be  due  to  a  direct 
check  to  the  tissue  metamorphoses.  Wood  has  shown  that  it  is  associ- 
17 


258  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

ated  with  diminished  excretion  of  carbonic  acid.  It  is  independent  of  the 
nerve-centres,  for  it  occurs  after  section  of  the  cord,  and  even  after  death 
in  those  cases  in  which  the  temperature  remains  high  or  rises.  Outside 
the  body  the  nitrite  has  a  remarkable  influence  over  oxidation — for  ex- 
ample, a  few  drops  introduced  into  a  jar  of  glowing  phospliorus  will 
extinguish  it.  Possibly  within  the  body  a  similar  effect  is  produced, 
though  not  so  complete,  or  instant  death  would  ensue.  Diminution,  not 
total  arrest  of  oxidation  probably  occurs.  All  highly  organized  tissues 
lose  power  in  the  presence  of  amyl.  Muscles,  nerves,  and  nerve-centres 
all  have  their  functions  restrained  or  suppressed  by  contact  with  it  ;  but 
if  the  contact  be  only  brief  the}'  recover  their  power,  so  that  the  poison 
does  not  destroy  the  vitality  of  the  tissues. 

Nitrite  of  amyl  is  very  rapidly  taken  up  by  the  blood,  on  which  it  ex- 
ercises a  remarkable  influence,  greatly  interfering  with  the  function  of  the 
red  corpuscles.  Under  its  influence,  both  the  arterial  and  venous  blood 
assume  a  chocolate  hue,  the  cause  of  which  has  been  carefully  investi- 
gated by  Dr.  Gamgee,  who  finds  that  the  nitrite  unites  with  ox3'h.iemo- 
globin  to  form  a  compound  which  is  in  its  turn  easily  broken  up  by  am- 
monia, and  by  reducing  agents.  He  found,  too,  that  blood  to  which  the 
nitrite  had  been  added  failed  to  take  np  an  appreciable  quantity  of  oxygen* 
Still  the  corpuscles  retain  in  some  degree  their  power  of  giving  up  ozone 
to  substances  having  an  affinity  for  it.  Thus  their  respirator}'  function 
is  not  abolished,  though  it  is  greatly  interfered  with.  The  poison  is  elim- 
inated by  the  kidneys  and  in  poisonous  doses  gives  rise  to  g-lycosuria, 
a  phenomenon  first  observed  by  J.  A.  Koffmann  {Reicherfs  Archives, 
1872)  when  experimenting  on  rabbits.  At  the  same  time  the  amount  of 
urine  is  increased.  Perhaps  disturbances  of  pressure  in  the  kidneys  and 
liver  may  account  for  these  symptoms. 

The  most  important  use  of  nitrite  of  amyl  is  in  angina  pectoris,  but  in 
other  cases  of  cardiac  failure,  as  for  instance  in  chloroform  narcosis,  it  has 
sometimes  been  successful.  Whenever  it  is  essential  to  lower  the  blood- 
pressure  rapidlv  it  may  be  effected  by  amyl.  Its  action  also  naturally 
indicates  it  as  likely  to  relieve  asthma  as  well  as  other  forms  of  spasm. 
As  soon  as  Dr.  Brunton  brought  it  forward  for  angina,  I  began  to  use  it 
to  relieve  spasm  of  the  bronchial  tubes,  and  obtained  excellent  results. 
I  have  seen  a  single  whiff  from  a  bottle  containing  a  few  minims  put  an  end 
to  a  severe  paroxysm  of  asthma,  but  sometimes  the  dyspnoea  returns  rather 
soon.  We  mav  then  repeat  the  inhalation  with  due  care,  but  it  is  not 
desirable  for  the  patient  to  become  habituated  to  the  remedy.  It  seems 
almost  necessary  to  intrust  him  with  it,  and  the  relief  is  so  rapid  and 
sometimes  so  complete  and  lasts  so  long  that  there  is  some  danger  of  his 
resorting  to  it  too  freely.  It  is  when  the  dyspnoea  is  accompanied  with 
pallor  of  the  face  that  this  remedy  may  be  tried  ;  when  the  superficial 
,  vessels  are  already  relaxed   it  is  inappropriate.     The  patient  should  also 


PNEUMATICS.  259 

be  instructed  to  leave  off  inhaling  the  moment  he  feels  the  flushing  begin, 
as  the  effect  will  continue  and  even  increase  for  a  short  time  after  this. 
Dr.  Kitchin  {Amer.  Jour.  Med.  Sci.,  1873)  has  used  it  in  acute  bronchitis 
as  well  as  asthma,  but  I  should  scarcely  resort  to  it  unless  distressino^ 
spasm  were  present. 

In  emphysema  and  cardiac  dyspnoea  it  is  not  so  successful,  and,  indeed, 
in  heart  disease  it  should  only  be  resorted  to  with  considerable  circum- 
spection. It  is,  as  already  stated,  to  take  off  blood-pressure  and  arrest 
spasm  that  it  is  chiefly  indicated,  though  it  has  naturally  been  tried  in 
many  diseases,  and  a  good  epitome  of  experience  concerning  it  will  be 
found  in  Dr.  Pick's  pamphlet.^ 

Kitro-ghjcerine  has  been  revived  by  Dr.  Murrell  ^  as  a  substitute  for 
amylnitrite  in  the  treatment  of  angina  pectoris,  and  it  mav  also  be  used 
as  an  antispasmodic  in  asthma,  whooping-cough,  etc.  Its  effects  come 
on  more  slowly  but  last  longer.  Many  years  ago  it  was  introduced  by 
Mr.  Field  {3Ied.  Times,  1858)  as  a  very  powerful  remedy,  giving  rise  to 
a  sensation  of  fulness  in  the  neck  and  head,  some  confusion,  noises  in  the 
ears,  etc.,  followed  by  headache.  And  he  strongly  recommended  it  in 
neuralgia  and  spasmodic  diseases.  His  statements  were  confirmed  by 
my  late  brother,  Mr.  Augustus  James,  then  a  student  at  University  Col- 
lege, by  Drs.  Thorowgood,  Brady,  and  others.  But  Drs.  G.  Ilarley  and 
Fuller  took  much  larger  quantities  without  any  effect,  and  their  state- 
ments no  doubt  largely  contributed  to  the  remedy  falling  into  neglect. 
It  seemed  obvious  to  me  at  the  time  that  there  were  considerable  differ- 
ences in  the  susceptibility  of  individuals  to  the  influence  of  nitro-glycer- 
ine.  My  brother  was  affected  severely  for  a  considerable  time  by  a  dose 
taken  in  my  presence  from  the  same  bottle  out  of  which  I  took  an  equal 
quantity,  but  in  my  case  the  effects  passed  off  in  a  few  minutes,  while  he 
was  affected  in  the  maimer  he  has  described  {]\Iedical  Times,  1858).  The 
average  dose  is  one  minim  of  a  one  per  cent,  solution,  wliich  may  be 
taken  in  water,  or  on  a  lump  of  sugar,  or  in  tablets  as  made  ])y  Martin- 
dale.  It  acts  on  the  blood  like  nitrite  of  amyl,  paralyzes  muscle,  and  de- 
stroys the  reflex  function  of  the  cord,  causing  death  by  asphyxia. 

Nitrite  of  sodium  has  also  been  found  to  produce  effects  similar  to 
those  caused  by  nitrite  of  amyl.  On  the  heart  and  vessels,  as  well  as  on 
the  blood,  the  action  seems  to  be  precisely  similar,  but  it  is  less  sudden 
and  less  energetic  ;  on  the  other  hand,  it  lasts  longer.  Dr.  Ralfe  brought 
it  before  the  Medical  Chirurgical  Society,  and  described  the  toxic  symp- 
toms to  which  doses  then  thought  small  had  given  rise.  Dr.  Ramskill 
corroborated  this,  and  it  has  been  shown  that  when  it  began  to  be  used 
impure  specimens  were  employed,  and  the  dose   therefore   of  the   pure 

'  Pick,  R.  :   Ueber  das  Amylnitrit  und  seine  therapeiitische  Anwendung.     1874. 
**  Murrell,  William  :  Nitro-glycerine  as  a  remedy  for  angina  pectoris.     1882. 


260  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

nitrite,  now  readily  obtained,  is  much  smaller  than  was  supposed.  Drs. 
Reichert  and  Matthew  Hay  have  shown  that  pure  nitrite  of  sodium  or 
of  potassium  will  act  like  the  nitrite  of  amyl  {Practitioner,  1883). 
Gamgee  has  shown  that  the  nitrites  act  on  the  blood  in  the  same  way  as 
the  amyl  compound,  and  Drs.  Ringer  and  Murrell  have  experimented 
{Lancet,  1883)  on  the  relative  activity  of  nitrites  and  nitrates  on  animals, 
and  employed  full  doses,  producing  unpleasant  symptoms  on  patients. 
When  used  it  would  be  desirable  to  begin  with  smaller  doses  than  have 
been  recommended,  say  two  to  three  grains.  Of  course,  the  alkaline 
nitrites  are  less  diffusible  than  the  amyl,  take  longer  time  to  be  absorbed, 
and  it  would  appear  that  they  are  more  depressant  to  the  central  nervous 
system,  while  they  also  act  on  the  peripheral  nerves  and  the  muscles,  not 
only  through  the  centre  but  by  local  access  through  the  circulation. 

Ethyl-iodide  or  hydriodic-ether,  C^H^I,  is  sometimes  inhaled  as  an 
antispasmodic  in  asthma  when  the  expectoration  is  scanty  and  tenacious. 
It  must  be  regarded  as  a  stimulant  to  the  air-passages,  and  of  course  it 
introduces  iodine  into  the  system  very  rapidly.  It  can  scarcely  be  re- 
garded as  anaesthetic.  Occasionally  the  relief  it  gives  in  spasmodic 
asthma  is  almost  instantaneous. 

Ether  and  Chloroform. — Without  producing  any  anesthesia  small 
quantities  of  ether  or  chloroform  when  inhaled  often  act  at  once  on  the 
respiratory  passages  and  arrest  spasm.  Even  spasm  of  the  glottis  may 
be  stayed  by  a  whiff  of  chloroform,  so  may  the  asthmatic  paroxysm  ; 
so  again  may  a  useless,  dry,  persistent  spasmodic  cough,  whether  arising 
from  irritation  in  the  respiratory  passages  or  in  the  nervous  system.  Yet 
these  vapors  unless  largely  diluted  are  A'ery  irritant.  The  use  of  chloro- 
form liniment  is  sufficient  to  show  this,  or  a  small  quantity  on  cotton 
"wool  with  a  covering  to  confine  the  vapor  will  be  found  an  active  rubi- 
facient  and  even  vesicant.  The  irritating  effect  of  the  vapor  of  ether  on 
the  respiratory  membrane  is  manifest  when  it  is  given  as  an  anaesthetic  ; 
cough  is  set  up  almost  always  and  very  often  some  blood-stained  mucus 
is  brought  up.  The  reason  we  do  not  see  this  in  using  chloroform  is 
probably  because  so  much  smaller  a  proportion  of  the  vapor  is  employed, 
from  three  to  four  per  cent,  being  sufficient,  and  we  give  ether  in  as  con- 
centrated a  form  as  we  can.  Dr.  Snow  '  stated  that  air  at  80°  F.  satu- 
rated with  ether  contained  about  seventy-one  per  cent,  of  the  vapor.  In 
practice  we  scarcely  reach  this  degree  of  concentration,  but  the  nearer 
it  is  approached  the  more  rapidly  anfesthesia  is  produced. 

How  is  the  antispasmodic  action  of  chloroform  and  ether  produced  ? 
In  larger  doses  we  know  that  the  respiration  and  circulation  are  both 
more  frequent  at  first  ;  but  very  soon  the  cardiac  and  respiratory  centres 

'  Snow,  J.  :  On  Chloroform  and  other  Anfesthetics,  their  Action  and  Administra- 
tion.    1858. 


PNEUMATICS.  261 

become  depressed,  the  pulse  falls  in  frequency  and  power,  and  the  breath- 
ing becomes  slow,  heavy,  and  stertorous.  Although,  therefore,  these 
vapors  may  act  upon  the  respiratory  nerves,  it  is  to  the  centre  we  must 
look  for  the  chief  explanation.  Ether  depresses  the  circulation  less  than 
chloroform  ;  the  heart  beats  after  respiration  has  been  arrested  by  ether, 
which  is  one  reason  of  its  greater  safety  ;  at  the  same  time  the  respira- 
tory centre  is  less  depressed,  though  we  must  not  forget  that  it  is  a  de- 
pressant eventually.  The  stage  of  stimulation  is,  however,  much  lono-er 
with  ether  than  chloroform  and  the  anaesthesia  is  briefer  and  not  so  deep. 
Comparatively,  therefore,  ether  is  sometimes  spoken  of  as  a  stimulant 
and  chloroform  as  a  narcotic.  Each  possesses  both  properties,  as  we  have 
explained  in  regard  to  other  narcotics,  but  the  exciting  stage  of  chloro- 
form quickly  passes  into  narcosis,  while  the  primary  effect  of  ether  is 
more  protracted  and  more  decided. 

Both  ether  and  chloroform  are  antispasmodics  when  administered  in- 
ternally. The  former  is  the  more  generally  used  for  this  purpose,  being 
more  exciting  and  commonly  regarded  as  a  powerful  diffusible  stimulant. 
They  are  both  carminatives.  As  soon  as  they  are  taken  into  the  stomach 
they  stimulate  the  circulation  and  the  nerve-supply  of  that  organ,  and 
act  reflexly  on  the  heart  and  respiratory  system.  At  the  same  time  a 
portion  is  at  once  absorbed  and  taken  by  the  circulation  to  the  nervous 
centres,  where  the  first  effect  is  excitant.  By  careful  dosage  we  mav 
contrive  to  confine  the  action  to  this  stage,  giving  only  enough  to  pro- 
duce excitement  and  taking  care  not  to  repeat  the  dose  until  time  has 
been  given  for  the  effect  to  pass  off,  so  as  to  prevent  accumulation.  This 
is  what  we  want  when  we  give  these  medicines  for  their  antispasmodic 
effect.  This  is  obtained  in  the  stage  of  stimulus  without  any  perceptible 
degree  of  narcotism  being  necessary.  Chloroform  is  much  more  pleasant 
to  take,  but  more  decidedly  narcotic.  Hence,  ether,  the  more  stimulant 
and  the  more  diffusible  and  so  the  more  evanescent  in  its  action,  main- 
tains the  first  place  as  an  antispasmodic,  but  by  careful  dosage — and  this 
is  all  in  all — spirit  or  tincture  of  chloroform  may  very  often  take  its  place 
and  in  some  cases  seems  to  be  preferable.  It  is  perhaps  better  suited  to 
gastro-intestinal  affections,  while  ether  is  far  superior  in  spasm  of  the 
respiratory  system.  Ether  may  be  given  in  capsules  or  pearls,  or  the 
spirit  of  ether  may  be  used,  but  the  compound  spirit,  the  old  Hoffmann's 
anodyne,  is  more  decidedly  antispasmodic.  Acetic  ether  has  been  intro- 
duced as  more  agreeable  in  taste  and  odor  and  therefore  more  appropri- 
ate as  a  carminative. 

Other  anaesthetics  naturally  possess  antispasmodic  properties,  but  as 
they  are  not  used  for  this  purpose  need  not  detain  us. 

Quebracho. — This  bark  has  been  lately  introduced  as  a  remedy  for 
dyspnoea,  and  is  said  to  be  especially  useful  in  emphysema  ;  it  may,  there- 
fore, perhaps,  be  called  antispasmodic  ;  but  both  the  bark  and  the  alka- 


262  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

loid,  aspidospennia,  reduce  the  frequency  of  the  respiration  as  well  as  the 
heart's  action  and  a'pparently  tlie  temperature,  probably  by  operating 
through  the  centre.  It  has,  however,  sometimes  been  said  that  quebracho 
stimulates  the  respiratory  system.  Manifestly  further  information  is 
needed  as  to  its  precise  action,  which  is  probably  rather  complex,  as  que- 
brachin  and  four  other  alkaloidal  substances  have  been  described  as  con- 
tained in  it  besides  aspidospermin.  The  dose  of  this  last  is  given  as  a 
quarter  to  half  a  grain.  A  tincture  of  the  bark,  one  in  five  of  proof 
spirit,  is  also  used  in  doses  of  five  to  sixty  minims  ;  the  drug  appears, 
however,  to  be  uncertain  in  its  action,  and  when  given  should  be  care- 
fully watched.  Probably  it  will  be  found  that  its  proper  place  is  among 
the  central  depressants,  though  it  may  possess  a  preliminary  stimulating 
action. 

Sedative  and  Anodyne  Pneumatics. 

These  have  naturally  been  named  in  the  other  groups,  but  may  be 
considered  together  for  a  moment  as  substances  the  use  of  which  is  in- 
dicated for  the  purpose  of  removing  pain  or  uneasy  sensations  in  the 
respiratory  organs,  and  for  restraining  their  excessive  action,  whether 
that  be  represented  by  spasm,  cough,  or  other  symptom.  It  is  obvious 
that  whatever  dulls  the  perceptive  faculties  will  seem  to  relieve  pain  or 
uneasiness.  The  sedative  or  anodyne  action  may  therefore  be  cerebral, 
annulling  consciousness,  as  in  the  case  of  anjesthetics,  or  diminishing-  it, 
as  by  narcotics.  So  it  is  also  clear  that  whatever  interrupts  the  con- 
veyance of  sensation  from  the  periphery  to  the  centre  will  appear  to  be 
sedative  or  anodyne.  Consequently  the  depressants  of  the  respiratory 
branches  of  the  vagi,  which,  as  we  have  seen,  are  antispasmodic,  are 
naturally  anodj'iies  to  the  respiratory  organs.  Further,  whatever  re- 
lieves the  mucous  membrane  or  other  tissue,  and  restores  healthy  breath- 
ing, may  claim  to  be  an  anodyne  pneumatic  ;  therefore,  moisture  and 
warmth,  when  the  membrane  is  swollen  and  dry,  are  remedies  of  this 
kind,  so  that  fomentations  and  hot  applications  acting  reflexly  may  give 
relief  ;  but  inhalations  of  warm  vapor,  bringing  the  remedy  in  contact 
with  the  surface  are  much  more  effectual.  But  we  are  concerned  here 
with  general  rather  than  topical  remedies.  Sometimes  expectorants  alone 
are  effectual,  inasmuch  as  they  cure  the  disease  ;  but  very  often  they  are 
not  required,  or  their  action  needs  modification  ;  therefore,  combinations 
with  opiates  or  other  neurotics  may  be  resorted  to,  or  a  dose  of  the  neu- 
rotic may  be  required  at  long  intervals,  while  small  quantities  of  the 
expectorant  are  given  more  frequently.  We  may  Use  for  this  purpose 
the  stimulant  depressant  or  alterant  expectorants,  according  to  circum- 
stances, combining  them  with  various  neurotics,  of  which  opium  is  per- 
haps the  most  frequently  employed.     But  belladonna  deserves  very  often 


PNEUMATICS.  26S 

the  preference.  As  these  neurotics  both  restrain  secretion,  they  may  be 
thought  to  be  therapeutically  incompatible  with  expectorants,  but  prac- 
tically this  is  not  the  case,  and  often  the  greatest  advantages  are  obtained 
by  the  judicious  combination  of  differently  acting  medicines.  Nowhere 
is  this  more  decidedly  the  case  than  in  diseases  of  the  respiratory  organs. 
And  the  combinations  of  the  various  pneumatics  appropriate  to  individ^ 
ual  cases  afford  ample  scope  for  the  exercise  of  the  therapeutical  knowl- 
edge and  skill  of  the  physician.  In  other  cases  our  anodynes  may  re- 
quire to  be  contra-expectorant,  or  we  may  turn  from  this  class  entirely 
and  employ  agents  which  act  directly  on  the  centre. 

CONTRA-EXPECTORANTS. 

These  are  medicines  which  diminish  the  sputa  by  restraining  the 
secernent  function  :  they  therefore  antagonize  expectorants.  Most  of 
them  have  been  considered  among  other  groups.  Thus  we  have  seen 
that  some  of  the  antispasmodics  restrain  secretion,  though  others  produce 
a  freer  flow  of  mucus.  So,  too,  some  of  the  sedatives  and  anodyne  pneu- 
matics restrain  secretion  and  antagonize  the  expectorants  ;  besides  these, 
neurotics  diminish  the  bronchial  mucus  ;  thus,  both  opium  and  bella- 
donna do  this,  though  their  action  on  the  nerve-centre  is  precisely  oppo- 
site. 

We  now  come  to  quite  a  different  class  of  remedies,  which  restrain 
secretion  whether  by  a  local  action  or  administered  through  the  system. 

Astringents,  among  which  may  be  included  certain  acids,  are  distinct 
contra-expectorants,  as  they  tend  to  diminish  the  amount  of  secretion,  and 
though  their  action  is  not  so  manifest  on  the  bronchial  membrane  as  on 
other  surfaces,  it  must  still  be  admitted  to  exist  and  may  sometimes  be 
utilized.  Some  of  our  most  valued  tonics  possess  astringent  properties, 
and  where  an  astringent  seems  to  be  required  in  bronchial  affections,  a 
tonic  of  this  character,  particularly  an  acid  one,  will  very  often  accom- 
plish all  that  we  require.  When  the  use  of  an  astringent  becomes  urgent 
to  restrain  bleeding  instead  of  secretion,  it  may  be  necessary  to  resort  to 
the  most  powerful  members  of  the  class,  but  generally  in  such  cases 
astringents  alone  are  not  to  be  relied  upon,  although  they  often  assist 
such  powerful  agents  as  complete  rest  and  other  appropriate  measures. 

Central  Pneumatics. 

These  are  such  remedies  as  produce  their  effects  by  a  direct  action  on 
the  respiratory  centre.  Such  action  may  be  of  two  kinds,  either  stimu- 
lant or  depressant;  the  first  giving  rise  to  more  active  respiratory  move- 
ments, the  other  retarding  them.  This  may  seem  to  be  a  sufficiently 
broad  line  of   distinction  between  tiie  two   groups,  but  if  we  try  to  tabu- 


264  THERAPEUTICS    OF    THE    KESPIRATORY    PASSAGES. 

late  the  central  pneumatics  we  shall  find  that  some  of  them  almost  claim 
a  place  in  each.  Tims  most  of  the  depressants  of  the  centi'e  cause  at 
first  some  excitement,  if  only  very  brief,  as  if  the  first  impression  on  a 
nerve  or  organ  excited  a  reaction  in  the  part  affected.  ^Ve  have  seen 
such  an  effect  in  cliloroform,  ether,  alcohol,  and  the  narcotics  general! v, 
which  appear  to  excite  before  they  depress,  the  duration  of  the  exciting- 
stage  rather  than  its  intensity  furnishing  the  most  important  distinction 
between  them.  Camphor  has  often  been  spoken  of  as  both  a  stimulant 
and  a  depressant  to  the  nervous  system.  So  far  as  the  respiratory  centre 
is  concerned,  it  seems  at  first  to  excite,  but  the  depressant  action  soon 
comes  on.  Then  stimulants  of  the  cardiac  centre,  many  of  which  act  also 
on  the  respiratory,  may  be  employed  for  the  latter  effect,  and  we  must 
remember  that  excitement  of  tlie  circulation  would  usually  be  accom- 
panied by  more  rapid  breathing,  whether  the  stimulus  directly  affected 
the  respiratory  centre  or  not.  Moreover,  cardiac  stimulants,  as  we  have 
seen,  are  mostly  followed  by  a  stage  of  depression,  and  we  have  to  vary 
our  mode  of  using  them  according  to  the  effect  we  are  desirous  of  pro- 
ducing. 

Opium — wliich,  as  we  have  seen,  distinctly  depresses  the  respiratory 
centre — has  a  full  preliminary  excitant  action  on  the  circulation,  or  pos- 
sibly at  first  a  slight  stimulating  effect  on  the  respiratory  centre,  so  slight 
as  to  be  disguised  by  the  circulatory  excitement,  and  so  brief  that  it  is  to 
be  regarded  as  a  characteristic  depressant  pneumatic.  So  it  has  been 
said  that  such  potent  depressants  as  prussic  acid,  tobacco,  and  calabar 
bean  exhibit  a  slight  but  evanescent  stimulating  effect,  which  is  soon 
quenched  in  the  profound  depression.  A  similar  course  of  events  may  be 
observed  in  respect  to  the  action  on  mucous  membrane,  those  which  in- 
crease secretion  and  even  depress  the  circulation  being  found  to  produce 
a  preliminary  ephemeral  stimulation.  Even  antimony  and  ipecacuanha 
are  said  to  act  in  tiiis  way,  both  on  the  centre  and  the  periphery,  but  the 
excitement  is  so  slight  that  it  can  seldom  be  detected,  and  can  never  be 
reckoned  on,  unless  it  is  to  be  maintained  that  the  promotion  of  secre- 
tion is  to  be  considered  as  necessarily  stimulating. 

In  the  same  way  it  is  to  be  observed  that  our  most  valued  stimulants 
of  the  respiratory  centre  tend  to  terminate  in  a  stage  of  depression,  or 
if  the  expression  be  preferred,  of  exhaustion.  Thus,  belladonna  in  too 
large  quantities  and  its  allies,  hyoscyamus,  stramonium,  and  datuia,  may 
finally  depress,  thougli  in  therapeutic  doses  the  real  value  is  the  powerful 
stimulant  action  on  the  centre,  which  sometimes  enables  us  to  maintain 
the  failing  respiratiori. 

The  difficulty  of  strictly  classifying  these  central  pneumatics  will  now 
be  apparent,  but  we  shall  take  the  ordinary  chief  therapeutical  action, 
and  disregard  so  far  the  minor  or  subsidiary  effects,  and  first  of  all  we 
will  consider 


PNEUMATICS.  265 

1.  Stimulants  of  the  Respiratory  Centre. — Arnmonia  is  perhaps 
the  most  important  of  these.  It  is  the  most  commonly  used  medicine  for 
this  jaurpose,  and  may  be  confidently  relied  upon  to  produce  a  rapid  ef- 
fect on  the  centre,  the  circulation  being-  at  the  same  time  powerfully 
stimulated.  As  we  have  seen,  it  is  also  an  expectorant,  promoting  the 
secretion  within  the  tubes,  its  action  on  the  centre  increasing-  the  cough- 
ing power  and  sustaining  the  breathing,  while,  of  course,  the  general 
stimulant  action  is  also  produced. 

JBellado)i7ia  and  Atropia. — This  remedy,  too,  we  have  previously  con- 
sidered at  length,  and  need  now  say  but  a  few  words  respecting  its  ac- 
tion on  the  centre.  It  is  a  most  valuable  stimulant,  the  next  perhaps  to 
ammonia,  if  not  its  equal,  for  sustaining-  the  failing  respiration  ;  the  action 
is  rapid,  beginning-  almost  immediately,  and  soon  passing-  off,  so  that  small 
doses  can  be  repeated.  The  pupil  is  not  a  sufficient  guide,  nor  is  dryness 
of  the  throat,  nor  dimness  of  vision  ;  these  are  symptoms  caused  by  full 
doses  and  are  somewhat  uncertain.  The  patient  should  be  watched  and  a 
small  dose  will  generally  cause  flushing,  which  is  a  sufficient  indication  of 
the  effect.  The  breathing  will  then  become  deeper,  and  when  it  again 
fails  a  dose  may  be  repeated.  It  will  be  remembered  that  atropia  also 
restrains  the  secretion  and  tends  to  dry  the  membrane,  in  this  respect 
being  contra-expectorant  and  opposing  anunonia  ;  at  the  same  time  it 
reinforces  the  drying  action  of  opium,  though  it  antagonizes  that  medi- 
cine in  other  directions,  as  we  have  already  shown  at  length  in  our  chajj- 
ter  on  neurotics. 

N'ux  Vomica  and  Strychnia. — The  medulla  is  very  powerfully  stimu- 
lated by  this  remedy.  The  vaso-motor,  the  cardiac,  and  the  respiratory 
centres  all  experience  its  influence  ;  some  of  the  effects  are  partially 
masked  by  the  powerful  stimulation  of  the  cord,  which  in  toxic  doses  ex- 
alts the  reflex  excitability  of  the  motor  dentres  to  so  great  an  extent. 
The  frequency  and  depth  of  the  respirations  are  increased  by  therapeuti- 
cal doses,  as  shown  both  by  experiment  and  observation.  Prokop  Roki- 
tanski  found  [Oesterreich  Med.  Jahrb.,  1874)  that  strychnia  caused  the 
respiratory  movements  to  reappear  after  they  had  been  abolished  by 
section  of  the  cord.  Dr.  Milner  Fothergill  found  that  strychnia  success- 
fully antagonized  lethal  doses  of  aconitia,  and  he  brought  it  forward  at 
the  International  Medical  Congress  in  London,  in  1881,  as  an  expectorant 
acting  through  the  centre.  Dr.  Lauder  Brunton  has  employed  it  to  check 
the  night-sweats  of  phthisis,  thinking  that  when  the  centre  becomes  ex- 
hausted the  accumulation  of  carbonic  acid,  being  no  longer  sufficient  to 
rouse  the  centre,  excites  the  sweat-glands.  He  therefore  gave  strychnia 
to  increase  the  excitability  of  the  centre  and  so  lead  to  more  perfect  res- 
piration. His  clinical  results  ("  St.  Bartholomew's  Hospital  Reports  ")  seem 
to  support  his  view.  Dr.  Thorowgood  has  also  used  this  remedy  in  em- 
barrassed respiration,  and  I  can  fully  confirm  its  value  as  a  stimulant  of 


2(3G  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

tlie  centre.  We  must  remember,  however,  that  it  excites  the  other 
centres.  Dr.  Fotliergill  also  suggested  to  the  Congress  tliat  strychnia 
should  be  employed  to  meet  the  disturbance  in  the  respiration  sometimes 
caused  bv  digitalis  ;  and  when  disease  in  the  lungs  or  air-passages  co- 
exists with  impairment  of  the  heart's  power,  he  would  combine  strychnia 
with  diii'italis  in  their  treatment.  For  this  purpose  I  use  tincture  of  digi- 
talis with  tincture  of  nux  vomica.  In  other  instances,  where  a  decided 
expectorant  is  required,  the  tincture  may  be  added  to  the  mixture  of 
senega  and  ammonia  ;  when  the  senega  is  not  tolerated  serpentary  is  a 
useful  adjunct.  Quinine  and  other  tonics  I  also  often  employ  in  conjunc- 
tion with  nux  vomica.  As  a  respiratory  stimulant  in  bronchitis,  emphy- 
sema, asthma,  and  phthisis,  whenever  it  is  desirable  to  increase  the  action 
of  the  centre,  I  regard  strychnia  as  a  most  valuable  remedy,  and  inasmuch 
as  it  also  acts  on  the  cardiac  centre,  it  is  at  the  same  time  a  tonic  to  the 
heart,  the  ganglia  of  which  it  also  rouses,  while  it  favorably  influences 
the  vessels  through  the  vaso-motor  centre,  by  which  the  arterial  pressure 
is  raised.  It  seems,  therefore,  appropriate  in  cardiac  dilatation  accom- 
panied by  diminished  vascular  tension. 

I  usually  select  strychnia  in  preference  to  atropine  when  a  more  pro- 
loiio-ed  effect  is  required  and  when  the  need  for  sustaining  the  centre  is 
nc ":  so  urgent.  The  remedy  takes  a  longer  time  to  produce  its  effect.  It 
is,  indeed,  absorbed  quickly  enough,  but  we  give  it  in  doses  which  have 
to  be  repeated  several  times  before  a  full  action  is  established  ;  it  is 
eliminated  rather  slowly.  It  seems,  therefore,  suited  for  keeping  up  a 
moderate  degree  of  stimulation  for  a  considerable  period.  It  also  affects 
the  circulation  less  than  belladonna.  AVhen  the  necessity  for  a  respira- 
tory stimulant  is  urgent,  I  use  atropia  or  belladonna  ;  the  effect  of  this  is 
much  more  rapid,  almost  immediate  ;  but  it  is  also  less  permanent.  I 
have  also  used  the  two  alkaloids  alternately,  giving  doses  of  atropia  from 
time  to  time  to  maintain  the  failing  movements  while  the  less  frequent 
doses  of  strychnia  were  gradually  accumulating.  I  would  not  hesitate 
to  produce  rather  quickly  the  physiological  effect  of  strychnia,  if  it 
seemed  to  be  needed  ;  but  this  is  seldom  the  case  in  my  experience,  for 
atropia  may  be  confidently  resorted  to  in  urgent  cases,  and  may  be  alter- 
nated with  ammonia.  I  have  therefore  come  to  regard  strychnia  as 
better  in  less  urgent  or  more  chronic  cases,  and  would  plead  for  its  more 
frequent  use  in  chronic  bronchitis  and  emphysema. 

The  use  of  strychnia  in  the  paralysis  that  sometimes  follows  diphtheria 
in  some  cases  of  laryngeal  paralysis,  and  for  other  purposes,  need  scarcely 
detain  us. 

2.  Depressants  of  the  Respiratory  Centre. — Some  of  these 
stimulants,  as  already  pointed  out,  may  at  a  late  stage  act  as  depressants, 
but  we  may  pass  them  by. 

The  nauseants,  especially  antimony  and  ipecacuanha,  are  decided  de- 


PNEUMATICS.  267 

pressants   of   the   centre,  so    much  so  as  at  times  to  be  contra-indicated 
when  otherwise  they  might  be  useful. 

Lobelia  and  tobacco  are  both  powerful  depressants,  but  have  been 
fully  considered  in  a  previous  article. 

Opium  is  the  most  constantly  useful  of  the  respiratory  depressants  ; 
we  have  seen  how  it  enters  into  a  considerable  number  of  our  groups, 
and  although  it  affects  the  entire  nervous  system — we  might  almost  say 
the  entire  organism — we  must  never  forget  the  special  depressant  action 
on  the  respiratory  centre  as  a  most  important  element  in  its  use  as  a 
pneumatic.  Paralysis  of  this  centre  is  the  cause  of  death  in  opium-poi- 
soning, and  its  depressing  influence  in  therapeutical  doses  comes  on  at  an 
early  period.  We  have  seen,  too,  how  it  restrains  bronchial  secretion, 
blunts  the  sensations,  impairs  the  action  of  the  vagi,  and  lowers  the  pul- 
monary circulation  as  well  as  the  general  blood-pressure.  Thus  the  en- 
tire effect  on  the  respiratory  organs  is  very  depressing-,  though  its  im- 
mense value  must  be  recognized  in  restraining  cough,  spasm,  dyspnoea, 
expectoration,  and  even  vascular  excitement  and  hajmoptysis.  Some  of 
the  undesirable  or  dangerous  effects  may  also  be  modified  or  prevented 
by  the  simultaneous  administration  of  other  remedies  acting  as  antago- 
nists to  it  over  a  portion  of  its  area  of  operation.  Combinations,  too, 
with  synergists  instead  of  with  antagonists,  as  well  as  with  various  other 
pneumatics,  may  also  render  the  greatest  service.  Further,  the  adminis- 
tration of  other  medicines,  even  such  as  scarcely  claim  to  be  considered 
pneumatics,  may  in  their  turn  advantageously  affect  the  narcotic  ;  and 
again,  an  occasional  opiate  miiy  be  ventured  upon  under  circumstances 
when  its  action  on  the  centre  might  suggest  that  it  would  be  scarcely 
appropriate.  The  action  of  opium  itself  is  very  complex,  and  he  will 
prove  himself  the  most  skilful  therapeutist  who,  whether  by  judicious 
combinations  or  alternations  with  other  medicines,  or  by  the  most  careful 
dosage,  is  able  to  obtain  the  greatest  benefit  for  his  patient. 

Chloral. — Chloral  acts  first  on  the  brain,  but  larger  doses  soon  in- 
volve the  medullary  centres,  which  are  much  depressed.  The  heart  is 
weakened  partly  through  the  centre,  but  a  full  dose  is  a  direct  cardiac 
poison,  retarding  and  enfeebling  the  beat  by  diminishing  the  excitability 
of  the  intrinsic  ganglia,  and  in  toxic  doses  the  ventricle  is  arrested  in 
diastole.  The  blood-pressure  likewise  falls,  apparently  from  a  direct  ac- 
tion on  the  vascular  walls  as  well  as  on  the  vaso-motor  centre,  which  is 
depressed.  Thus  there  is  altogether  a  very  considerable  weakening  of 
the  circulation,  tending  toward  its  arrest,  while  at  the  same  time  the 
respiratory  centre  is  deeply  depressed  and  the  breathing  rendered  slower 
and  feebler,  a  little  later  irregular  and  shallow,  and  ultimately  it  is  com- 
pletely arrested.  These  effects  have  been  observed  after  section  of  the 
vagi,  and  so  must  be  attributed  to  the  influence  on  the  centre.  There  is 
a  remarkable  fall  in  the  temperature. 


268  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

In  spite  of  its  powerful  effect  chloral  has  been  used  to  restrain  spasm, 
cough,  and  dyspnoea,  but  it  very  frequently  fails  to  do  so,  and  alto- 
gether in  respiratory  diseases  it  is  much  less  useful  than  opium,  though  it 
is  probably  more  risky,  and  when  there  is  any  fear  of  the  centre  becom- 
ing exhausted  it  is  very  dangerous.  Moreover,  large  doses  seem  to  favor 
congestion  of  the  lungs  and  air-passages.  In  acute  inflammation  of  these 
parts  it  is,  therefore,  to  be  avoided.  It  is  useless  as  an  anodyne  and 
not  much  use  as  an  antispasmodic  ;  though  it  has  sometimes  relieved 
asthma,  it  more  frequently  fails.  In  whooping-cough  and  laryngismus  it 
is  perhaps  more  successful  when  given  in  small  doses  two  or  three  times 
a  day,  but  even  in  these  cases  it  is  inferior  to  the  bromides,  and  should 
for  the  most  part  be  reserved  as  a  hypnotic,  for  which  purpose  it  is  in- 
valuable. 

Bromides  depress  the  respiratory  centre,  and  to  tliis  influence  is  per- 
haps due  their  effect  in  relieving  spasmodic  diseases  of  the  respiratory 
system.  But  tlie  depression  is  by  no  means  confined  to  this  part  ;  the 
other  centres  in  tlie  medulla  are  also  affected  and  probably  all  parts  of 
the  nervous  system,  though  much  of  the  influence  on  the  brain  is  to  be 
traced  to  the  effect  on  the  cerebral  circulation.  Tlie  depression  of  the 
cardiac  centre  is  not  very  marked  ;  true,  the  heart  is  weakened  and  re- 
tarded by  the  medicine,  but  this  appears  to  be  largely  due  to  direct  ac- 
tion on  the  nervo-muscular  substance  rather  than  on  the  centre,  which 
explains  the  value  of  the  remedy  in  certain  nervous  disorders  of  the 
heart.  The  tension  seems  to  be  reduced,  but  the  effect  on  the  vessels  is 
hardly  settled.     The  temperature  is  usually  somewhat  lowered. 

The  bromides  are  absorbed  readily  and  elimination  begins  at  once 
through  the  saliva  and  urine.  The  salt  usually  passes  away  unchanged  ; 
the  largest  portion  leaves  the  system  during  the  first  day,  but  as  Clarke 
and  Amory  '  have  shown,  elimination  goes  on  longer  ;  on  the  second  day, 
after  a  single  large  dose,  the  amount  removed  is  much  less  than  on  the 
first,  and  the  reduction  goes  on  until  elimination  is  complete.  Namias 
reported  ( Gazette  Sebdom.,  1868)  that  when  bromide  had  been  taken 
for  a  considerable  period  its  excretion  might  not  be  complete  for  fourteen 
days.  Disease  of  the  kidney  renders  the  process  slower,  and  Dr.  Lees 
mentioned  to  the  Pathological  Society  ("  Trans.,"  1877)  a  case  in  which  it 
vpas  found  four  weeks  after  the  medicine  was  discontinued.  Rabuteau, 
operating  upon  large  quantities  of  urine,  found  a  salt  of  bromine  at  such 
a  distance  of  time  that  he  came  to  regard  it  as  a  natural  constituent 
{Gazette  Hehdoni.,  1868)  of  the  body.  Armory  found  that  a  single 
dose  was  removed  almost  entirely  in  one  day,  but  some  of  it  often  re- 
mained until  the  second  day.     After  continuous  doses  it  lingered  longer 

'  Clarke,  Edward  H.,  Amory,  Robert:  The  Physiological  and  Therapeutical  Action 
of  Bromide  of  Potassium  and  Bromide  of  Ammonium.     1873. 


PNEUMATICS.  269 

in  the  system.  Namias  found  i^Comptes  Rendus,  tome  Ixx.)  bromide  of 
potassium  in  all  the  fluids  as  well  as  in  the  brain,  lungs,  liver,  and  other 
viscera  of  a  man  who  had  died  while  taking  a  course  of  that  medicine. 
Some  elimination  has  been  supposed  to  go  on  upon  the  mucous  mem- 
branes, and  Voison  {Bull.  gen.  de  Therap.^  Ixxi.)  has  stated  that  the 
breath  has  a  strong  odor  of  bromine  after  the  continued  use  of  the  salt, 
so  that  he  supposed  it  might  be  decomposed  to  some  extent  in  the  res- 
piratory passages,  and  the  volatile  element  escape,  and  he  and  others  ob- 
served that  hoarseness,  cough,  and  laryngeal  and  bronchial  irritation 
sometimes  followed  the  use  of  the  drug.  But  Amory  and  Clarke  con- 
clude {pp.  cU.)  that  it  is  not  eliminated  by  the  breath,  and  regard  the 
odor  observed  by  M.  Voisin  as  one  which  is  produced  equally  by  other 
salts  of  potassium,  after  the  use  of  which  they  say  a  fetid  smell  is  often 
given  o£E  and  a  disagreeable  taste  experienced  by  the  patient.  Eche- 
verria  '  noticed  that  this  odor  occurred  earlier  and  to  a  greater  degree  in 
persons  who  did  not  attend  rigidly  to  the  cleanliness  of  the  teeth  ;  a 
similar  effect  is  observed  in  persons  who  have  a  habit  of  biting  and  chew- 
ing up  portions  of  the  lining  of  the  mouth  and  lips.  The  laryngeal 
symptoms  observed  are  generally  attributed  to  impurities  in  the  medi- 
cine ;  a  very  small  contamination  with  iodate  will  bring  on  catarrhal  symp- 
toms. The  skin  assists  in  the  elimination  on  the  second  day,  and  the 
eruptions  so  well  known  to  occasionally  follow  the  use  of  bromides  may 
perhaps  be  due  to  a  local  action.  The  effect  on  the  circulation  is  less 
marked  than  on  tlie  nervous  system,  but  must  not  be  forgotten  as  an  im- 
portant element  in  the  action. 

It  will  be  observed  that  the  action  of  the  bromides  is  rather  slow, 
compared  with  the  iodides  ;  or  again,  compared  with  chloral  the  effect  is 
slower  but  more  protracted,  so  that  in  so  far  as  the  respiratory  system 
is  concerned,  chloral  and  the  bromides  are  to  each  other  as  depressants  of 
the  centre  much  the  same  as  belladonna  and  strychnia  are  to  each  other  as 
stimulants  ;  and  here  is  one  danger  of  chloral  and  the  great  recommenda- 
tion of  the  bromides.  We  do  not  really  want  to  suddenly  depress  the  cen- 
tre in  the  manner  in  which  it  is  so  often  most  urgent  to  suddenly  stimu- 
late it.  Therefore,  the  quick-acting  stimulant  is  often  called  for,  but  the 
quick-acting  depressant  is  rather  to  be  avoided  when  possible,  though  the 
slower  and  less  intense  depressant  action  of  the  bromides  may  not  be  in- 
jurious ;  in  some  instances  it  is  manifestly  desirable,  and  constantly  it 
is  allowable  in  order  to  secure  the  other  remarkably  valuable  effects  on 
the  nervous  system. 

The  bromides  are  useful  in  spasmodic  respiratory  disorders  ;  they 
sometimes  relieve  laryngismus  and  prevent  the  recurrence  of  the  par- 
oxysms, and  thus  enable  the  tonic  and  hygienic  measures  so  often  neces- 

'  Echeverria,  Gonzalez  :  On  Epilepsy. 


270  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

sary  to  be  brought  into  play.  In  whooping-cough  the  value  of  the 
bromides  was  pointed  out  by  Gibb  '  and  corroborated  by  Dr.  G.  Harley 
{^Lancet,  1863).  In  asthma  the  bromides  have  been  freely  emploved, 
both  during  the  paroxysm  and  the  interval  ;  more  successfully  in  the 
latter  case.  Professor  See  {Bull,  de  Theraj).,  1865)  found  that  it  de- 
layed the  attacks,  as  did  Dr.  Warburton  Begbie  {Edin.  Med.  Joitrncd, 
1866),  and  M.  Saison  published  a  remarkable  case  in  which,  after  full 
doses  for  a  fortnight,  no  further  paroxysms  occurred  ("Du  Bromaure," 
These,  1868).  The  same  author  recommended  this  remedy  in  recurrent 
tonsillitis,  .but  it  appears  to  have  little  influence,  and  would  probably 
only  be  of  use  to  persons  in  whom  it  was  otherwise  indicated.  '  In  phthi- 
sis it.  is  sometimes  useful  in  relieving  spasmodic  laryngeal  cough,  though 
it  very  often  fails  to  do  so,  and  is  not  appropriate  where  there  is  much 
ansBmia  or  depression.  In  this  disease,  also,  it  will  restrain  dysphagia 
when  that  assumes  a  spasmodic  character  and  there  is  a  good  deal  of 
irritation  but  no  severe  disease  in  the  larynx.  Of  course  it  would  only 
aggravate  this  symptom  if  it  arose  from  any  degree  of  paresis.  In 
diphtheria  these  salts  have  been  taken  internally  and  used  locally,  with 
the  addition  occasionally  of  some  pure  bromine.  The  records  are  not 
very  encouraging. 

In  resorting  to  the  bromides  in  respiratory  diseases,  they  may  often 
be  advantageously  given  in  combination,  or  alternately  with  other  reme- 
dies, partly  for  the  purpose  of  reinforcing  their  action,  as  by  chloral, 
cannabis,  opium,  aconite,  etc.;  but  more  frequently  with.a  view  of  modi- 
fving  the  effect  or  preventing  disagreeable  consequences.  The  antago- 
nism of  strychnia  to  the  bromides  Avas  observed  by  Saison,  and  has  since 
been  confirmed.  He  examined  post  mortem  the  spinal  centres,  after 
using  the  two  medicines,  and  found  that  after  bromides  the  capillaries 
were  scarcely  visible,  but  after  strychnia  they  were  intensely  congested. 
As  the  effect  of  strychnia  on  the  brain  is  so  much  less  than  on  the  cords, 
we  may  partially  neutralize  the  spinal  action  of  bromides  without  inter- 
fering much  with  their  cerebral  influence,  and  this  is  occasionalh'  an  ad- 
vantage. Combinations  with  opium  are  also  sometimes  of  service.  Da 
Costa  {Amer.  Jour.  Med.  Sciences,  1871)  has  shown  that  it  is  easy  to 
correct  the  disagreeable  action  of  opium  by  preceding  it  Avith  a  dose  of 
bromide,  and  that  with  no  loss,  but  rather  with  a  gain  in  the  hypnotic 
effect.  So  arsenic  is  sometimes  given  simultaneously  to  prevent  or  re- 
move the  cutaneous  complication  set  up  by  bromides.  Dr.  Bill  in  a 
very  interesting  article  holds  that  chloride  of  sodium  {Amer.  Jour.  Med. 
Sciences,  1868)  is  in  some  degree  antagonistic  to  bromide  of  potassium. 
Atropia  and  ergot  are  both  partially  antagonistic,  but  both  also  may  at 
times  be  advantageously  combined  with  bromide.     In  some  cases  expec- 

'  Gibb,  G.  D. :  Treatise  on  Whooping-cough.     1854. 


PNEUMATICS.  271 

torants  and  other  pneumatics  are  advantageously  given,  while  the  system 
is  kept  more  or  less  under  the  influence  of  bromide. 

The  potassium  salt  is  most  commonly  used.  The  ammonium  salt 
has  been  freely  employed,  and  seems  of  late  to  grow  in  favor,  but  it  is 
the  more  nauseous  of  the  two,  and  seems  also  to  be  more  irritatino-  to 
mucous  membranes,  for  which  reason  it  is  perhaps  less  appropriate  when 
there  is  much  bronchial  irritation.  It  has  also  been  thought  to  be  more 
evanescent.  Brown-Sequard  '  found  that  the  union  of  the  two  salts  in- 
creased the  sedative  action  of  the  dose.  The  bromide  of  sodium  is  less 
depressing,  less  likely  to  irritate  mucous  membranes,  and  rather  less 
disagreeable  in  taste.  As  in  other  instances,  I  have  been  led  to  prefer 
the  sodium  salt  ;  the  dose  is  a  little  less,  as,  weight  for  weight,  it  con- 
tains more  bromine.  Bromide  of  lithium  is  still  more  powerful,  contain- 
ing about  ninety-two  per  cent,  of  bromine  against  seventy-eight  of  the 
sodium  salt  and  sixty-six  of  the  potassium.  I  have  found  a  smaller 
dose,  that  is  to  say,  a  dose  proportionate  to  these  figures,  thoroughly 
effectual,  less  disagreeable  to  take,  and  sometimes  successful  when  the 
other  salts  fail.  Probably  absorption,  and  perhaps  elimination,  may  be 
a  little  more  rapid,  for  sleep  comes  on  more  quickly  after  the  lithium 
salt.  It  may  be  preferred  in  gouty  and  rheumatic  constitutions.  Dr. 
Weir  Mitchell  speaks  as  favorably  (Amer.  Jour.  Med.  -Sci.,  1870)  of  the 
hypnotic  qualities  of  this  preparation.  JBromide  of  calcium  is  another 
active  salt.  It  has  not  come  much  into  favor,  perhaps  because  it  is 
rather  unstable,  but  it  has  a  value  of  its  own.  Hammond  has  found  it 
succeed  after  the  potassium  has  failed,  and  I  would  once  more  urge  the 
more  frequent  use  of  this  and  other  calcium  salts.  Charcot  has  recom- 
mended {Brit.  Med.  fTour.,  1877)  hromide  of  zinc,  and  some  other 
metallic  bromides  have  been  employed,  so  have  combinations  with 
quinine  and  other  organic  bases  ;  while  hydrohromic  acid  has  been 
supposed  to  produce  many  of  the  effects  of  the  alkaline  bromides  with- 
out causing  so  much  depression,  but  it  is  more  frequently  used,  merely  to 
prevent  quininism  than  to  produce  the  effects  of  bromine. 

Prussic  Acid. — The  dilute  hydrocyanic  acid  of  the  pharmacopcBias, 
United  States  and  British,  contains  only  two  per  cent,  of  this  powerful 
poison,  which  is  absorbed  with  great  rapidity  and  produces  its  deadly  ef- 
fects most  swiftly.  It  changes  the  red  corpuscles  and  converts  the 
venous  blood  to  a  bright  arterial  color  which  speedilv  turns  black.  The 
first  change  seems  to  check  the  function  of  the  corpuscles,  the  second  to  de- 
stroy them,  reduction  of  oxyhsemoglobin  being  effected  and  cyanohfemo- 
globin  formed.  This  body,  discovered  by  Hoppe-Seyler,  has  no  ozon- 
izing power,  at  the  same  time  some  cyano-oxyhfemoglobin  seems  also  to 

'  Brown-Scqiiard  :  Lectures  on  the  Diagnosis  and  Treatment  of  Functional  Xervous 
Affections. 


272  THERAPEUTICS    OF    THE    RESPIRATOKY    PASSAGES. 

be  formed,  hut  these  changes  which  liave  been  well  studied  out  of  the 
body,  and  which  no  doubt  occur  in  cases  of  poisoning,  do  not  altogether 
account  for  the  therapeutical  effects  which  appear  to  be  largely  produced 
by  an  action  on  the  nervous  tissues,  all  of  which  are  greatly  depressed. 
As  soon  as  ever  the  poison  is  taken  tlie  respirator}'^  centre  feels  the  im- 
pulse, and  after  a  momentary  excitement  is  greatly  depressed,  so  that  the 
respiration  falls,  dyspncea  ensues,  and  asphyxia  follows.  It  has  been 
held  that  at  the  same  time  the  respiratory  nerves  are  dejoressed  and  re- 
flex respiratory  acts  arrested,  especially  when  the  poison  is  inhaled,  but 
Preyer  '  says  that  after  division  of  the  vagi  letlial  doses  did  not  kill, 
though  Boehm  and  Knie  {Arcliiv  f.  exper.  Path.  u.  Tlierap.)  found  that 
section  of  the  vagus  had  no  influence  on  the  respiratory  action  of  the 
poison. 

The  vaso-motor  centre  is  affected  like  the  respiratory  ;  so  also  is  the 
cardiac,  but  this  in  a  much  less  degree,  so  that  the  heart  continues  to 
beat  for  some  time  after  respiration  has  ceased. 

A  full  medicinal  dose  may  cause  giddiness,  disturbed  breathing,  and 
syncope  ;  this  effect  may  be  so  rapid  as  to  cause  great  alarm.  No  doubt 
great  differences  in  the  preparation  have  occurred,  and  it  is  unfortunate 
that  in  dealing  Avith  so  powerful  a  medicine  more  than  one  preparation 
should  have  been  in  common  use.  The  so-called  Scheele's  acid  was  much 
stronger  than  that  of  the  Pharmacopoeia,  and  also  somewhat  uncertain  in 
its  strength.  It  is,  therefore,  a  source  of  regret"  that  a  few  physicians 
should  still  insist  on  using  it.  The  officinal  acid  is  strong  enough  for  all 
therapeutical  purposes,  and  a  dose  of  one  to  three  minims  need  not  be 
exceeded.  The  dose  given  by  the  British  Pharmacopoeia  is  much  too 
high  ;  indeed,  it  may  be  said  to  be  quite  double  Avhat  it  ouglit  to  be.  The 
British  Pharmacopoeia  gives  two  to  eight  minims,  but  very  few  people 
happily  will  prescribe  this  maximum.  K  case  has  been  communicated  to 
me  in  which  a  patient,  after  four  minims,  fell  down  in  a  state  of  breath- 
lessness,  which  was  at  first  thought  by  friends  to  be  fainting,  but  the 
great  dyspnoea,  constriction  of  the  chest,  confusion  and  giddiness  with- 
out loss  of  consciousness,  convinced  them  that  the  medicine  just  swal- 
lowed was  the  cause  of  the  symptoms,  and  they  sent  for  the  gentleman 
who  had  prescribed  it  in  the  greatest  alarm.  As  he  happened  to  be 
near  he  arrived  in  time  to  see  the  effect,  which  left  a  severe  headache 
and  sense  of  prostration  for  several  hours.  Admitting  that  there  may 
have  been  some  unusual  susceptibility  in  this  case,  considering  that  many 
other  persons  who  have  taken  a  less  dose  have  experienced  headache  and 
other  unpleasant  symptoms,  my  contention  seems  reasonable  that  the 
officinal  dose  is  too  large.  Moreover,  as  the  effect  of  the  medicine  in 
small  doses  is  very  evanescent,  it  can  be  repeated  every  two   or  three 

'  Preyer,  W. :  Die  Blausaure.     1870. 


PNEUxMATICS.  273 

hours,  and  in  most  of  the  cases  in  which  it  is  likely  to  prove  useful  small 
and  frequent  doses  will  be  found  most  desirable.  In  my  experience  two 
or  three  minims  always  suffice,  and  more  frequently  one  to  two. 

The  chief  use  of  hydrocyanic  acid  is  to  allay  troublesome  spasmodic 
cough  in  phthisis,  asthma,  and  whooping-cough.  It  probably  acts  botli 
on  the  centre  and  on  the  peripheral  nerves  ;  by  this  latter  action  it  also 
arrests  vomiting,  for  which  it  is  often  employed,  and  this  also  makes 
it  specially  useful  in  some  cases  of  phthisis.  We  know  that  locally  it 
allays  irritation,  as  we  sometimes  see  on  the  skin,  and  perhaps  this  is 
why  the  inhalation  of  the  vapor  is  occasionally  so  effectual.  The  high 
value  placed  on  this  remedy  by  Majendie  '  is  not  easy  to  account  for,  in 
view  of  tlie  disappointment  to  wiiich  it  constantly  gives  rise.  The  still 
more  extravagant  praises  of  Dr.  Granville,'  who  seemed  to  think  it  could 
cure  advanced  phthisis,  did  not  perhaps  exercise  the  influence  of  the 
eminent  physiologist's  confidence.  Dr.  Elliotson  '  defined  its  sphere  in 
dyspepsia.  Dr.  Roe*  had  much  confidence  in  its  value  in  simple,  uncom- 
plicated cases  of  whooping-cough,  but  gave  it  in  doses  which  Sir  T.  Wat- 
son in  his  lectures  pronounced  "gigantic."  Still  Dr.  West^  admits  it 
sometimes  "exerts  a  magical  influence,"  and  Dr.  Atlee  [Ai/i.  J.  Med.  S.) 
gives  a  favorable  report  based  on  two  hundred  cases.  Dr.  Lonsdale  made 
some  interesting  experiments  {Ediii.  M.  and  S.  J.,  1838)  and  Dr.  Nun- 
neley  contributed  others  ("Trans.  Prov.  Med.  and  S.  Ass.,"  1847).  The 
more  recent  researches  have  already  been  cited,  and  a  review  of  the 
whole  evidence  will,  I  think,  confirm  my  estimate  of  its  therapeutical 
value. 

Cherry-laurel  is  only  of  use  for  the  prussic  acid  it  contains,  and  being 
of  uncertain  strength  is  best  avoided.  Its  introduction  into  the  British 
Pharmacopoeia  is  greatly  to  be  regretted. 

Cyanide  of  potassium  produces  the  same  effects  as  hydrocyanic 
acid.  Five  grains  have  several  times  proved  fatal,  and  it  is  not  improb- 
able that  half  that  quantity  will  cause  death.  The  medicinal  dose  would 
be  a  tenth  to  an  eighth  of  a  grain.  Cyanide  of  zinc  has  also  been  em- 
ployed, and  is  included  in  the  French  Codex  ;  dose,  one-fourth  of  a  grain. 
Some  other  cyanides  have  been  used,  but  not  as  substitutes  for  the  acid. 

Physostigma,  after  a  very  brief  stimulation,  powerfully  depresses  the 
respiratory  centre,  death   being  due  to  failure  of  the  respiration.     It  has 

'  Majendie,  F.  :  Reclierclies  pliysio'ogiques  et  cliniqnes  siir  I'emploie  de  I'acide 
Prussiqiie,  etc.     1819. 

-  Granville,  A.  B.  :  Internal  Use  of  Hydrocyanic  Acid  in  Pulmonary  Complaints, 
etc.     1819. 

'Elliotson,  J.  :  Cases  Illustrative  of  the  Efficacy  of  Hydrocyanic  or  Prussic  Acid, 
etc.     1820. 

^Roe,  Gr.  Hamilton  :  Treatise  on  Whooping-cough.     1838. 

*  West,  Charles :  Lectures  on  Diseases  of  Infancy  and  Childhood.     1854. 
18 


274  THERAPEUTICS    OF   THE    EESPIRATORT    PASSAGES. 

been  used  in  several  spasmodic  affections.  Subbotin  speaks  well  of  it 
(Archiv  f.  klin.  Med.,  18G9)  in  clironic  bronchial  catarrh,  attended  with 
dyspncjea.  We  have  already  mentioned  its  antagonism  to  atropia.  It 
can  scarcely  be  said  at  present  to  have  obtained  a  position  as  a  respira- 
tory remedy. 

Aco7iite  and  veratria,  although  they  depress  the  respiratory  centre, 
are  employed  rather  for  their  effects  on  the  circulation,  which  have 
already  been  considered.  A  similar  observation  may  be  made  as  to  gel- 
semium. 

Conium  may  be  mentioned  here,  and  has  been  used  more  or  less  from 
the  time  when  Socrates  drained  the  fatal  cup  presented  by  the  Athen- 
ians, But  although  the  ancients  employed  it  as  a  medicine,  it  fell  into 
disuse  until  Baron  Stoerck  '  revived  it  in  a  treatise  of  nearly  three  hun- 
dred and  fifty  pages,  which  he  followed  by  a  second  smaller  work  and  be- 
sides that  a  '•  supplement,"  all  three  of  which  were  in  a  short  time  trans- 
lated into  English.  No  one  can  doubt  that  Stoerck's  statements  are 
highly  colored,  as  indeed  his  contemporaries  asserted,  but  the  interest  he 
excited  secured  a  long  trial  for  the  drug,  and  a  very  considerable  litera- 
ture accumulated  concerning  it,  of  which  Bayle  has  furnished  us("Biblio- 
theque  de  Therapeutique,"  1835)  an  excellent  summar}-.  Sir  Charles 
Scudarnore  added  conium  to  his  iodine  inhalations  ;  and  in  our  own  time 
Dr.  J.  Harley  ^  has  carefully  studied  its  action  and  shown  how  it  may  be 
intensified  by  opium.  A  further  important  study  of  the  subject  has  been 
made  by  Martin-Damourette  and  Pelvette.^ 

Conia  or  cotiine  seems  to  have  been  discovered  by  Brandes  and  Gie- 
secke  in  1826,  and  was  isolated  by  Geiger  in  1831,  but  the  first  important 
examination  of  its  properties  was  by  Professor  R.  Christison  ("Trans. 
Royal  Soc.  Edinburgh,"  1836).  It  appears  that  the  herb  contains  also 
an  essential  oil  which  is  not  poisonous,  and  a  crystalline  base,  couhydrin, 
which  is  less  poisonous  than  conia.  This  last  is  a  yellowish,  strong-smell- 
ing, oily  liquid,  more  soluble  in  cold  than  hot  water,  very  unstable,  very 
])oisonous,  and  when  locally  applied  an  irritant.  It  may  be  dissolved 
in  alcohol,  and  it  forms  salts  which  are  more  manageable  than  the  alka- 
loid. Conia  is  readily  taken  into  the  system,  where  it  has  been  supposed 
to  be  destroyed,  but  Zaleski  and  Draggendorff  have  detected  it  in  the 
urine,  and  Orfila  found  some  in  the  spleen,  kidneys,  and  lungs  of  animals 
poisoned  by  it.     Perhaps  on  account  of  its  volatility  it  may  easil}'  escape 

'  Stoerck,  A.  :  Libellns  quo  demonstratur  Cicutara  non  solum  uso  interne  tutissimo- 
exhiberi  sed  et  esse  simnl  remedium  valde  utile  in  miiltis  morbis.     1760-1.     Also,  Li- 
bellns secnndns  qno  confirmatur,  Cicntam  usu  interno  ti;tissime   adhiberi,  etc.     1761. 
Also,  Snpplenientum  necessarinm  de  Cicuta.     1761. 

-  Harley,  John  :   The  Old  Vegetable  Neurotics.     1869. 

^  Martin-Damonrette  et  Pelvette  :  Etude  de  physiologie  experimentale  et  th6ra- 
peiitique  sur  la  CiguG  et  son  Alcaloide.     1871. 


PNEUMATICS.  275 

in  the  breath.  Its  chief  action  is  on  the  motor  nerves,  paralysis  taking 
place  first  in  the  extremities  and  proceeding  upward.  In  the  end  the 
respiratory  centre  as  well  as  the  nerves  are  paralyzed,  and  death  ensues 
from  asphyxia.  But  it  is  not  so  entirely  without  effect  on  sensory  nerves 
as  has  often  been  said.  Gubler  {^Bull.  de  TTierap.,  1875)  found  that  it 
numbed  cutaneous  sensibility,  and  Lautenbach  i^Phil.  3Ied.  Times,  \o\.  v.) 
declares  that  it  greatly  impairs  the  functions  of  the  peripheral  afferent 
nerves.  It  is  not  a  hypnotic  or  a  narcotic,  as  was  once  supposed,  and  its 
great  use  is  to  restrain  excitement  of  the  motor  system. 

Conia  locally  applied  is  extremely  irritant,  and  probably  fatal  to  the 
more  highly  organized  tissues.  Christison  {loc.  cit.)  proved  this  in  regard 
to  muscular  fibre,  and  yet  we  use  it  as  a  sooth  nig  inhalation.  When 
mixed  with  hot  water  it  rises  with  the  vapor,  but  curiously  enough  its 
own  boiling  point,  unmixed,  is  much  higher  than  that  of  water.  It  would 
appear  that  in  ordinary  inhalations  the  vapor  is  so  diluted  that  it  no 
longer  irritates  the  mucous  membrane,  and  some  local  effect  is  exercised 
on  the  nerves  ;  at  the  same  time,  by  its  central  action  it  tends  to  relieve 
spasm.  The  British  Pharmacopoeia  vapor  is  a  bad  preparation  ;  in  fact, 
we  have  been  very  unfortunate  in  our  officinal  preparations  of  hemlock  ; 
the  extract  is  very  often  useless,  and  the  mixture  of  it  with  liquor  po- 
tasses a  method  of  dissipating  the  small  amount  of  alkaloid  that  may  be 
present  in  a  superior  specimen.  The  best  way  is  to  employ  the  succus, 
the  only  useful  preparation  in  the  British  Pharmacopoeia,  and  the  alkali 
ought  to  be  added  at  the  time  of  use,  so  that  what  conia  separates  may 
be  inhaled.  Moreover,  an  alkaline  carbonate  is  best.  This  vapor,  care- 
fully prepared,  I  have  found  very  soothing  in  laryngeal  phthisis  and 
some  other  diseases.  Internally  the  succus  may  be  used  in  whooping- 
cough  and  other  spasmodic  affections  ;  it  must  be  continued  until  the 
physiological  effects  are  manifest.  The  new  United  States  Pharmaco- 
poeia has  an  abstract  and  a  fluid  extract,  but  I  have  not  yet  fully  tried 
them.  Perhaps  a  salt  of  the  alkaloid  will  in  time  become  more  frequently 
used. 


CHAPTER  XIX. 

TOPICAL  PNEUMATICS. 

The  attempt  to  introduce  vapors  or  fumes  into  the  air-passages  dates 
from  the  most  remote  antiquity,  and  the  attempt  to  vary  the  conditions 
of  the  atmosphere  must  be  quite  as  ancient.  It  could  not  but  be  that  the 
pernicious  effects  of  fogs  should  be  noticed  at  the  earliest  period,  and 
that  men  should  not  only  avoid  as  far  as  they  could  what  seemed  injuri- 
ous, but  should  Avhen  ill  attempt  to  subject  themselves  to  opposite  con- 
ditions. The  breathing  of  various  emanations  from  the  earth,  especially 
in  the  neighborhood  of  volcanoes,  was  probably  also  resorted  to  in  the 
earliest  ages,  just  as  other  natural  agents  were  employed,  either  accident- 
ally or  from  superstition  ;  and  plants  which  were  not  found  to  be  edible 
have  been  used  as  medicines  by  most  uncivilized  tribes. 

Fumigations  with  cyphi  (ki)^i)  entered  into  the  practice  of  the  ancient 
Egyptians,  these  cyphi  being,  according  to  Dioscorides,  a  mixture  of 
various  drugs,  and  as  the  Egyptians  had  made  great  advances  in  the  use 
of  spices,  balms,  and  other  odorous  medicines,  it  is  probable  that  these 
entered  largely  into  their  cyphi.  As  soon  as  men  began  to  use  warm 
baths,  indeed,  as  soon  as  they  made  water  hot,  they  would  become  ac- 
quainted with  its  vapor,  and  probably  notice  the  soothing  effect  of  breath- 
ing steam,  and  endeavor  to  turn  it  to  useful  account. 

The  early  Greeks  were  well  acquainted  with  the  use  of  inhalations 
and  fumigations,  and  handed  their  knowledge  down  to  the  Romans,  from 
whom  the  Arabian  school  obtained  it.  Then  it  may,  perhaps,  be  said 
that  wherever  incense  was  burned  in  religious  ceremonies  the  effect  of 
breathing  it  must  have  been  noticed,  and  to  it  would  probably  be  as- 
cribed the  greatest  benefit  both  curative  and  preventive.  Homer  men- 
tions fumigations  with  sulphur  ("  Iliad,"  xvi.,  228,  and  "  Odyssey,"  xxii., 
481).  Hippocrates  frequently  recommends  the  inhalation  of  vapors  and 
fumes  of  various  balsamic  and  resinous  substances,  and  on  his  authority 
these  remedies  long  held  a  high  place  in  the  practice  of  his  successors. 
He  even  describes  an  apparatus  for  the  purpose,  consisting  of  a  sauce- 
pan with  a  hole  in  the  lid  through  which  a  reed  was  passed.  As  the 
vapor  escaped  it  was  inhaled  through  the  open  mouth,  wet  sponges  being 
employed  to  prevent  scalding  the  lips.     The  works  of   Hippocrates   fur- 


TOPICAL    PNEUMATICS.  277 

ther  show  his  knowledge  of  the  effects  of  air  and  the  use  of  change  of 
climate.  Galen's  genius  and  erudition  are  only  equalled  by  his  practical 
sense  and  observation,  and  we  know  the  reliance  he  placed  on  this  class 
of  remedy.  A  little  later  flourished  Ccelius  Aurelianus,  the  only  Roman 
methodist  whose  works  have  descended  to  us,  and  though  this  sect  re- 
jected previous  opinions,  and  ridiculed  the  Hippocratic  system,  terming 
it  a  "  meditation  on  death,"  we  find  this  author  '  recommended  inhala- 
tions and  fumigations.  Pliny  had  already  recorded  ("  Hist.  Nat.")  that 
in  his  time  diseases  of  the  lungs  were  believed  to  be  benefited  by  a  resi- 
dence among  pine-trees,  so  that  the  inhalations  could  pass  into  the  air- 
passages,  and  Celsus  ("  De  Medicina ")  recommended  sea  voyages  to 
consumptives.  As  the  Arabians  took  their  inspiration  from  Hippocrates 
and  Galen,  they  handed  down  this  method  of  treatment,  extending  it 
by  the  numerous  medicines  and  compounds  which  they  added  to  the 
recognized  materia  medica. 

During  the  dark  ages,  when  the  incubus  of  an  apostate  church  weighed 
down  the  nations  of  Europe,  medicine  largely  passed  into  the  hands  of  a 
corrupt  priesthood,  many  of  whom  were  vicious,  many  ignorant,  and  not 
a  few  both.  But  while  they  lost  many  other  valuable  remedies  and  re- 
placed them  by  superstitious  observances,  they  recognized  the  value  of 
fumigation,  though  they  may  have  attributed  its  use  to  religious  obser- 
vances. On  the  revival  of  learning,  men  turned  back  with  impatience  to 
the  writings  of  the  Greeks,  and  soon  the  spirit  of  inquiry  in  various  de- 
partments added  to  what  had  been  previously  known.  In  the  sixteenth, 
seventeenth^  and  eighteenth  centuries  a  large  number  of  writers  recom- 
mended frankincense,  myrrh,  amber,  camphor,  styrax,  assafcetida,  cloves, 
sulphur,  the  balsams,  and,  indeed,  all  strongly  odorous  fumes  and  vapors 
as  a  method  of  applying  remedies  directly  to  the  bronchial  membrane. 
Benedict  in  his  "  Theatrum  Tabidorum  "  recommended  this  method  of 
treating  consumption,  and  Boerhaave  in  his  "Materia  Medica"  furnished 
a  number  of  formulre  for  such  fumigations.  Dr.  Mead  recommended  fumes 
produced  by  throwing  the  medicament  on  hot  coals  to  be  inhaled  through 
a  tube,  and  regretted  the  undeserved  neglect  into  which  this  plan  had 
fallen  in  his  day,  and  bore  testimony  to  the  signal  service  he  had  obtained 
from  balsamic  fumes  thus  employed.  Alberti  ^  described  the  use  of  vari- 
ous inhalations  and  Buxtorf  ^  and  Caccialupi*  wrote  treatises  on  the 
subject. 

Toward  the  close  of  the  last  century  a  series  of  brilliant  discoveries 
directed  attention  to   the  elastic  gases.     It  is  true   that   hydrogen  had 


'  Aurelianus,  Caelius:  De  morbis  Chvon. ,  lib.  iii.,  c.  4. 
'  Alberti,  M.  :   Dissertatio  de  spirandi  difficultate.     1726. 
^  Buxtorf,  J.  R.  :  De  inhalatione.     1758. 

^  Caccialupi,  A.  :  De  usn  et  prsestantia  Halituum,  Vaporum,  Suffituumque  in  morbis 
respiratiouis  organa  obsidentibus.     1795. 


278  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

been  discovered  a  little  earlier,  namely,  in  176G,  by  Cavendish  ("  Phil, 
Trans.,"  17GG),  but  it  was  not  till  1774  that  Priestley'  announced  the 
discovery  of  oxygen,  and  Scheele  that  of  chlorine,  while  two  years  later 
Priestley  discovered  nitrous  oxide,  Tliis  gas  received  its  name  of  nitrous 
oxide  from  Sir  Humphry  Davy,^  whose  remarkable  researches  respecting 
it  have  a  special  interest,  inasmuch  as  he  foreshadowed  the  use  of 
anaesthetics  in  surgery.  Dr.  Beddoes  ^  took  up  the  subject  of  elastic 
gases  and  their  use  in  medicine  with  great  energy,  and  had  the  advan- 
tage of  Sir  H,  Davy's  assistance.  He  tried  the  various  gases  in  a  great 
number  of  diseases,  and  recorded  their  effects  with  care.  He  was  fol- 
lowed by  Hill,''  Cavallo,*  and  others,  and  in  another  work  he  "  himself 
recommended  the  inhalations  of  In'drogen  mixed  with  air  as  a  remedy 
for  consumption,  on  the  assumption  that  in  that  disease  there  was  ex- 
cessive oxygenation.  He  prescribed  inhalations  for  about  fifteen  min- 
utes at  a  time,  to  be  used  several  times  a  day.  About  this  time  the 
value  of  acids,  chlorate  of  potash,  and  other  substances  containing  a  con- 
siderable proportion  of  oxygen  was  often  attributed  to  that  element  be- 
ing liberated  in  the  system,  as  it  was  not  till  sometime  later  that  Wohler 
and  Stehberger  {ZeitscJirift  f.  PJtys.,  18'34)  showed  that  these  med- 
icines were  eliminated  unchanged. 

Under  the  influence  of  the  impetus  thus  given  to  the  inhalation  of 
gases,  even  carbonic  acid  mixed  with  air  was  freeh'  tried  again  ;  for  it 
had  been  previously  employed  by  Percival,'  who  considered  that  it  ameli- 
orated the  febrile  symptoms  of  phthisis,  in  wiiich  he  was  confirmed  by 
Hulme,*  Beddoes,^  Cavallo,"  and  some  others.  The  lat^  observers 
thought  that  it  lessened  the  stimulation  of  oxygen,  which  they  considered 
excessive  in  consumption,  and  that  it  also  relieved  hectic  and  expectora- 
tion. Brera  "  recorded  some  important  observations  respecting  this  gas, 
which  was  also  tried  by  Priestley,'^  who,  however,  turned  his  attention  to 

'  Priestley,  J.  :  Experiments  and  Observations  on  Different  Kinds  of  Air.  3  vols. 
1775-77. 

■"'Davy,  Sir  Humphry:  Researches  Chemical  and  Philosophical  chiefly  concerning 
Nitrons  Oxide.     1800. 

^Beddoes,  T. ,  and  Watts,  J.  :  On  the  Medicinal  Use  and  Production  of  Factitious 
Airs.     1796. 

*  Hill,  D.  :  Practical  Observations  on  the  Use  of  Oxygen  or  Vital  Air  in  the  Cure 
of  Diseases.     1800. 

*  Cavallo,  T.  :  On  the  Medicinal  Properties  of  Factitious  Airs  ;  with  Ajipendix  on 
Blood.     1798. 

*  Beddoes,  T. :  On  a  New  Method  of  Treating  Pulmonary  Consumption. 
^  Percival,  T.  :  Essays,  Medical  and  Experimental.     3  vols.      1773-76. 

^  Hulme,  N.  :  Easy  Remedy  for  the  Relief  of  Stone,  Gravel,  Scurvy,  Gout,  etc. 
1778.  9 Beddoes:  Op.  cit.  i" Cavallo :  Op.  cit. 

"Brera,  V.  L.  :  Osservazioni  e  sperienze  suU' uso  delle  Aere  Mefitiche  inspirate 
nella  Tisi  Pulmonare.     1796. 

'-  Priestley,  J.:  Directions  for  Impregnating  Water  with  Fixed  Air.     1773. 


TOPICAL    PjSTEUMATICS.  279 

its  use  in  solution  in  water.  lu  the  hands  of  Miihry '  inlialations  of 
carbonic  acid  entirely  failed  to  relieve  consumption.  Although  carbonic 
acid  continued  to  be  used  in  a  number  of  diseases,  we  cannot  affect  sur- 
prise that  it  could  not  maintain  the  position  which  these  writers  assign 
to  it.  It  may  be  stated,  however,  that  it  can  be  used  when  mixed  with 
air  more  easily  than  might  be  supposed,  and  it  is  sometimes  resorted  to 
at  Ems,  St.  Moritz,  and  other  places  in  the  present  day.  The  good  ef- 
fect believed  to  arise  from  sleeping  in  cow-houses  and  stables  was  also 
supposed  to  depend  on  the  carbonic  acid  in  the  air,  but  perhaps,  if  it  ex- 
isted, it  was  rather  due  to  the  warmth  and  moisture  present.  It  has  also 
often  been  remarked  that  asthmatics  sometimes  breathe  easier  in  the  close 
air  of  large  towns,  than  in  the  country,  and  this  also  has  been  attributed 
to  the  carbonic  acid  ;  but  it  may  quite  as  likely  depend  on  some  other 
condition,  and  it  is  by  no  means  a  general  rule.  Tlie  relief  sometimes 
afforded  to  asthmatics  by  the  fumes  of  nitre  papers  has  also  been  attrib- 
uted to  the  same  agency. 

At  the  opening  of  the  present  century  AYard  °  collected  a  number 
of  observations  on  inhalations,  and  Zallony  ^  employed  them  freelv, 
while  Dr.  Paris  ■*  advised  the  evaporation  of  water  in  the  rooms  of  his 
patients  during  tlie  prevalence  of  dry  east  winds,  as  well  as  other  modes 
of  inhalation.  A  little  later  than  this  Sir  Alexander  Crichton  ^  turned 
back  to  tar  vapor,  as  an  inhalation  in  phthisis,  in  which  he  was  followed 
by  Lazzaretto,"  and  Hufeland.'  About  this  time,  also.  Dr.  Forbes  [Med. 
and  Phys.  Journ.,  1822)  and  Pagenstecher  {HufelaiuVs  Journal,  1827) 
advocated  the  use  of  inhalations  of  tar,  which  continued  to  hold  their 
ground  until  quite  recently,  Sales-Girons  ■*  recommending  them,  in  addi- 
tion to  the  pulverized  liquids  with  which  his  name  is  so  honorably  con- 
nected, and  some  others,  especially  in  France,  employing  them  at  the 
present  time.  But  this  use  of  the  fumes  of  tar  was  largely  superseded 
by  creasote,  as  recommended  by  its  discoverer,  Reichenbach,  whose  re- 
searches excited  no  little  attention.  Elliotson  at  once  employed  creasote 
inhalations  in  phthisis,  as  did  Miquet  and  Cormack.  The  writings  of 
these  four  authors  have  already  been  cited  in  the  article  on  creasote,  and 

'  Miihry,  G.  F.:  De  Aeris  fixis  iuspirati  usu  in  Flithisi  Puluaouali.     1796. 

2  Ward,  G.:   De  Medicina  Pueumatica.     1800. 

3  Zallony  :  Trait j  de  Tasthme.     1809. 

*  Paris,  J.  A.  :  Pharmacologia.     1812.     Ninth  edition,  1843. 

5  Crichton,  Sir  A.  :  Acconnt  of  some  Experiments  made  with  the  Vapor  of  Boiling 
Tar  in  the  Cure  of  Pulmonary  Consumption.     1817. 

^Lazzaretto,  E.  :  Practical  Hints  on  the  Natnre  and  Cure  of  Consnmption,  with 
Cases  in  Proof  of  the  Beneficial  Effects  of  Inhaling  the  Fumes  of  Pitch,  as  a  Powerful 
Auxiliary  to  other  Treatment.     1818. 

'  Hiifeland,  C.  W. :  System  der  Pract.  Heilkunde.     3  vols.     1818-28. 

^  Sales-Girons :  Traitement  de  la  Phthisic  pulmonaire  par  I'iuhalation  des  liquides 
pulverises  et  par  les  fumigations  de  goudrou.     1860. 


280  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

may  be  supplemented  by  Frueh's '  work.  These  inhalations  are  still 
used,  and  often  render  good  service  in  various  affections  of  the  respira- 
tory passages.  Creasote  has,  however,  fallen  into  comparative  neglect  since 
the  introduction  of  carbolic  acid,  which  is  now  so  extensively  emploved. 

To  return.  Murray  ^  and  Scudamore  ^  turned  to  iodine  in  the  hope 
that  its  vapor  might  prove  to  be  an  effectual  remedy  in  phthisis  and 
other  respiratory  diseases.  They  were  gratified  with  the  results  obtained, 
and  it  is  not  surprising  that  their  expressions  of  confidence  are  somewhat 
exaggerated  and  scarcely  supported  by  their  cases.  Those  of  Dr.  Bards- 
ley  *  certainly  inspire  more  confidence.  The  use  of  iodine  inhalations 
became  gradually  extended,  and  their  value  in  some  conditions  of  the 
air-passages  is  now  generally  acknowledged  ;  though  we  no  longer  enter- 
tain the  hope  that  this  or  any  other  agent  will  prove  a  panacea. 

While  so  much  attention  was  being  directed  to  the  inhalation  of 
vapors  and  gases  it  was  not  likely  that  chlorine  would  be  overlooked,  and 
accordingly  we  find  that  this  powerful  irritating  and  suffocating  gas, 
when  adequately  diluted,  was  tried  as  an  inhalation.  Gannal  ^  gives  an 
account  of  eight  cases  of  consumption  in  which  diluted  chlorine  appeared 
to  him  to  alleviate  the  symptoms  and  prolong  life.  Jn  one  case  recovery 
was  said  to  have  taken  place,  but  then  the  only  proof  of  the  existence  of 
tubercle  was  the  presence  of  general  symptoms.  Elliotson  "  and  other 
physicians  also  employed  these  inhalations  in  various  diseases,  and  with 
somewhat  conflicting  results.  At  the  present  time  we  employ  the  vapor 
chlori  as  a  stimulant  and  disinfectant  inhalation  in  bronchiectasis,  ad- 
vanced phthisis,  and  in  gangrene  of  the  lungs.  The  air  of  bleaching- 
w^orks  is  believed  by  many  residing  near  them  to  be  effectual  in  the  cure 
of  chronic  coughs,  and  they  sometimes  resort  to  these  works  for  that  pur- 
pose; and  it  has  been  reported  that  the  bleachers,  although  they  may 
suffer  from  the  emanations  of  chlorine,  are  jjarticularly  free  from  con- 
sumption. 

We  have  already  seen  that  sulphur  fumigations  have  been  employed 
from  time  immemorial;  we  need  not,  therefore,  dwell  on  them  specifically, 
but  pass  on  to  the  more  general  subject  of  the  various  kinds  of  inhala- 
tions.    Many  of  these  are  described  by  Maddock,'  and  about  the  same 

^  Frueli,  G.  :  Ueber  die  Anwendung  desKreaosots  in  der  Pneumophthisis.     Ib36. 

^  Murray,  James  :  On  the  Influence  of  Heat  and  Humidity  ;  with  Practical  Obser- 
vations on  the  Inhalation  of  Iodine  and  Various  Vapors  iu  Consumption,  Catarrh, 
Croup.  Asthma,  and  other  Diseases.     1829. 

^  Scudamore,  Sir  Charles  :  Op    cit. 

^  Bardsley,  J.  L.  :   Hospital  Facts  and  Observations.     On  Iodine,  etc.     1830. 

*  Gannal,  J.  X.  :  Du  Chlore  emiiloye  comme  rem'de  contra  la  Phthisie  Pulmonaire. 
1830.  6  Elliotson  :  Op.  cit. 

'  Maddock,  A.  B.  :  Cases  of  Piilmonary  Consumption,  Bronchitis,  Asthma,  Chronic 
Cough,  and  Various  Diseases  of  the  Lungs,  Air-passages,  Throat,  and  Heart  Success- 
fully Treated  by  Medicated  Inhalations.     1837. 


TOPICAL    PNEUMATICS.  281 

time  Dr.  Coxe  '  urged  their  curative  power.  A  little  later  than  this  a  very 
remarkable  impulse  to  the  study  of  inhalation  was  given  by  its  applica- 
tion for  the  purpose  of  producing  anaesthesia  during  the  performance  of 
surgical  operations,  the  year  1847  being  remarkable  for  the  appearance 
of  between  thirty  and  forty  pamphlets  respecting  the  new  discovery,  and 
the  next  year  being  almost  as  fruitful.  Somewhat  later  Sylvestri  ^  gave 
a  full  account  of  the  subject  of  inhalation  and  Desruez  ^  published  his 
practical  guide  to  this  method  of  treatment. 

At  many  continental  spas  inhalation-rooms  were  i^rovided  in  which 
the  steam  of  the  mineral  waters  was  employed,  but  of  course  it  was  felt 
that  none  of  the  mineral  constituents  were  present,  and  ordinary  water 
might  have  been  employed  for  the  same  purpose.  The  idea  of  atomiz- 
ing the  mineral  waters  seems  to  have  originated,  or  at  any  rate  to  have 
been  first  carried  into  effect  by  Auphan  at  Euzet-les-Bains  in  ISiO  ;  he 
projected  a  jet  of  the  mineral  water  on  the  wall  of  the  inhaling-room 
Avith  sufficient  for^e  to  break  it  up  into  a  spray,  which  was  inhaled  by 
his  patients.  This  method  was  adopted  at  several  spas.  But  at  length 
Sales-Girons  constructed  a  portable  apparatus  for  atomizing  fluids,  and 
brouo-ht  it  before  the  Academv  of  Medicine  of  Paris  in  1858.  This  was 
undoubtedly  an  epoch  in  the  history  of  inhalations,  and  the  gTcatest 
interest  was  excited.  It  was  not,  however,  till  1862  that  the  committee 
of  the  Academy  appointed  to  investigate  the  new  method  brought  in 
its  report,  and  during  the  interval  prolonged  discussion  had  taken  place 
as  to  whether  the  spray  penetrated  deeply  into  the  air-passages.  Tlie 
report  stated  that  it  was  proved  that  both  the  water  and  the  mineral 
constituents  employed  penetrated  not  only  to  the  bronchi  but  even  to 
the  air-cells  ;  and  this  report  was  founded  on  extensive  independent 
experiments  and  was  almost  unanimously  adopted  by  the  Academy. 
The  conclusions  and  practice  of  Sales-Girons,^  who  has  been  called  the 
Father  of  Atomization,  thus  received  the  highest  authority  aTid  rapidly 
spread  over  the  civilized  world.  Demarquay  ^  vvas  one  of  the  earliest 
to  adopt  it,  and  to  prove  independently  that  tlie  atomized  liquids  rapidly 
pass  into  the  respiratory  passages. 

'  Coxe,  E.  J.  :  Practical  Treatise  on  Medical  Inlialation  and  its  Curative  Powers  in 
Bronchitis,  Consumption,  and  other  Diseases  of  the  Respiratory  Organs.     1841. 

'-'  Sylvestri,  G.  :  La  Pneumojatria  ossia  I'arte  di  curare  le  malattie  coi  medicamenti 
sotto  forma  gazosa,  giusta  le  expeiienze  di  rinomati  medici  antichi  e  moderni.     1851. 

"  Desriiez,  J.  M.  R.  :  Inspirations  Pulmonaires  ou  Fumigations  internes  ;  guide 
pratique  de  la  methode  thorapeutique.     1854. 

•*  Sales-Girons  :  Therapeutique  Respiratoire :  Traite  th'oriqiie  et  pratique  des  Sal- 
les  de  Respiration  nouvelles  (a  I'eau  minorale  pulvcrisoe)  dans  les  etablissements 
thermaux  pour  le  traitement  des  maladies  de  poitrine.     1858. 

^Demarquay  :  Memoire  sur  la  p='netration  des  Liquides  Pulverises  dans  les  voies, 
respiratolres  et  leur  application  au  traitement  des  maladies  des  yeux,  du  pharynx,  et 
du  larynx.     1862. 


282  THERAPEUTICS    OF    THE    EESPIKATORY    PASSAGES. 

It  seems  surprising  that  this  should  have  been  doubted,  considering 
that  solid  particles  are  constantly  introduced  in  the  cases  of  workmen 
engaged  in  certain  trades  and  give  rise  to  serious  diseases,  e.g.,  miner's 
lung,  and  grinder's  disease.  Dr.  Bergson  simplified  the  apparatus  by 
employing  a  pair  of  tubes  fixed  at  right  angles,  one  descending, vertically 
into  the  liquid  to  be  atomized,  the  other  for  driving  the  air  through. 
Siegle  substituted  steam  for  the  bellows,  and  Dr.  Beigel  added  a  screen, 
for  which  a  tube  is  sometimes  substituted,  to  direct  the  spray  into  the 
mouth. 

Methods  of  I^'haling. 

When  we  wish  only  to  change  the  conditions  under  wliich  respiration 
is  carried  on,  we  may  to  some  extent  do  this  by  change  of  air  or  change 
of  climate,  and  instances  have  already  been  mentioned  in  which  patients 
have  been  sent  to  localities  where  they  could  breathe  certain  emanations 
from  the  earth  or  air  laden  with  artificial  impurities.  The  atmosphere 
of  gas-works,  bleaching-works,  stables,  and  other  places  has  often  been 
resorted  to  by  the  public. 

Attempts  have  also  been  made  to  change  the  air  in  a  patient's  room. 
The  most  familiar  instances  is  wlieu  we  add  moisture  and  raise  tlie  tem- 
perature. In  addition  to  this,  the  liberation  of  elastic  gases  has  also 
been  tried  ;  thus  oxygen  has  been  set  free  in  the  room  in  the  hope  thereby 
of  providing  an  atmosphere  in  which  respiration  should  be  carried  on 
more  efficiently.  On  the  other  hand,  hydrogen  and  even  carbonic  acid 
have  been  set  free  with  a  view  of  restraining  oxidation.  This  method  is 
difficult  to  manage,  ventilation  is  essential,  the  diffusion  of  gases  rapid, 
and  we  have  no  mode  of  measuring  in  what  degree  such  a  plan  can  op- 
erate in  an  ordinary  room.  Of  course,  in  specialise  constructed  chambers 
this  process  might  be  carried  out  for  short  periods,  but  for  a  longer  time 
the  necessity  of  ventilation  defeats  our  efforts. 

The  liberation  of  irritating  gases,  such  as  chlorine  or  sulphurous  acid, 
is  easy  enough,  as  very  small  quantities  speedily  make  their  presence 
known,  and  only  such  small  quantities  can  be  tolerated.  The  fumes  ob- 
tained from  burning  nitre  papers  are  rapidly  diffused  through  the  apart- 
ment, and  can  be  approximately  measured  by  using  definite  sizes  of  paper 
saturated  in  solutions  of  known  strength.  The  amount  of  sulphurous  acid 
liberated  may  be  regulated  by  burning  a  known  weight  of  sulphur.  Pas- 
tilles of  definite  strength  can  be  made  for  this  purpose.  The  fumes  of 
tar  may  be  obtained  by  boiling,  or  by  simply  stirring  with  a  hot  poker. 

Turpentine,  by  reason  of  its  volatility  only  requires  to  be  sprinkled 
about  a  room  to  secure  a  portion  of  the  vapor  being  perceptible  in  the 
air  for  a  considerable  period,  and  it  can  easily  be  removed.  A  solution 
of  carbolic  acid  may  be  employed  in  the  same  way,  but  it  is  less  volatile. 


TOPICAL    PNEUMATICS. 


283 


and  when  we  wish  to  secure  its  full  effect  it  is  necessary  either  to  vapor- 
ize it  or  to  distribute  the  solution  over  a  considerable  surface,  which  may 
be  accomplished  by  dipping  towels  or  sheets  in  a  solution  of  known 
strength  and  suspending  them  as  curtains  by  the  doors,  and  if  necessary 
by  the  windows  or  any  other  openings,  so  that  the  entering  air  must 
traverse  them.  This  has  been  done  lately  at  the  Victoria  Park  Hos- 
pital, and  Dr.  Heron  calculates  {^Lancet,  September  6,  1884)  that  patients 
in  the  inhalation-room  pass  seven  cubic  feet  of  carbolic  vapor  through 
their  lungs  in  twenty-four  hours.  But  for  a  room  to  be  permanently  used 
in  this  manner,  special  provision  ought  to  be  made  for  ventilation. 
Even  when  a  room  is  only  used  for  a  short  time,  it  is  not  an  easy  matter 
to  keep  up  a  definite  supply  of  the  substance  with  which  the  air  is  to  be 
laden.  Dr.  Hassall  has  constructed  a  special  inhalation-chamber  at  San 
Remo,  in  which  he  has  endeavored  to  accomplish  this  {Lancet,  1884).  But 
it  is  often  inconvenient,  or  even  impossible  to  resort  to  a  special  chamber, 


Fig.  1 — Bumstead's  Vaporizer. 


and  therefore  various  modes  of  evaporating  carbolic  acid  and  other  sub- 
stances are  employed.  Such  a  vaporizer  as  is  here  shown  will  very 
quickly  fill  an  ordinary  room  with  the  vapor  of  carbolic  acid,  eucalyptus, 
or  other  volatile  antiseptics,  and  it  will  keep  on  evolving  small  quantities 
for  about  three  hours  without  needing  a  fresh  supply.  For  this  purpose 
the  little  lamp  has  only  to  be  trimmed  with  oil,  taking  care  that  the 
wick  is  short,  as  a  very  small  flame  is  suflicient.  Indeed,  in  the  absence 
of  a  lamp  an  ordinary  night-light  will  give  off  sufficient  heat,  and  too 
much  will  be  produced  if  the  lamp  be  filled  with  spirit  or  petroleum. 

Iodine  gives  off  its  vapor  at  a  low  temperature,  and  a  little  of  the  ele- 
ment may  be  placed  in  a  watch-glass,  and  this  floated  on  a  saucer  of 
hot  water.  Balsamic  substances  maybe  thrown  upon  live  coals  or  heated 
over  a  lamp. 

In  order  to  diffuse  an  increased  amount  of  moisture  through  the  air 


2S-i 


TIIKUAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 


a  saucer  containing  water  is  often  placed  on  a  stove  when  that  method  of 
warming  is  employed.  For  an  open  fire  or  gas-stove  an  ordinary  croup 
kettle,  which  has  a  long  tube  to  project  into  the  room,  may  be  used. 

For  the  same  purpose,  as  well  as  to  permeate  the  apartment  either 
with  aqueous  vapor  alone  or  combined  with  carbolic  acid,  a  steam-draught 
inhaler  may  be  employed. 

In  these  cases  a  supply  of  steam  is  diffused  through  the  air  ;  but 
sometimes  instead  of  vaporizing  the  water  we  may  simply  atomize  it,  and 
in  this  case  it  carries  with  it  particles  of  such  solids  as  it  may  contain  in 
solution.     In  this  way  attempts  have  been  made   by  employing   salt  to 


Fia.  2. — Croup  Kettle. 


Fig.  3. — Steam-clraiight  Inhaler. 


fill  the  patient's  room  .with  a  kind  of  artificial  sea  air.  Any  of  the  larger 
sized  spray-producers  will  answer  for  this  purpose. 

When  we  do  not  desire  to  charge  the  air  with  the  remedy,  but  only 
to  supply  such  an  amount  as  the  patient  can  use  for  a  short  time,  we  have 
to  resort  to  inhalers. 

For  the  elastic  gases  a  very  simple  apparatus  will  suffice  ;  but  Earth's 
oxygen  inhaler  is  the  most  convenient,  and  this  gas  may  be  produced 
condensed  in  strong  metallic  bottles,  from  which  a  given  quantity  can  be 
let  into  the  inhaler  as  required.  Limosin  had  an  apparatus  made  to  lib- 
orate  the  oxygen  at  the  time  of  use,  and  Robbins  also  contrived  an  in- 
haler for  this  purpose,  but  I  have  always  used  the  condensed  oxygen. 
For  nitrous  oxide  Earth's  apparatus  is  also  excellent. 


TOPICAL   PNEUMATICS. 


285 


For  iodine  Nelson's  inhaler  can  be  used,  but  it  is  better  to  have  one 
of  glass,  such  as  is  here  figured,  wliich  will  also  serve  for  chlorine. 

For  steam  inhalations  a  very  simple  plan  is  to  breathe  through  a  large 


Fio.  4. — Iodine  Inhaler. 


cup  sponge  which  has  been  dipped  in  hot  water  and  rapidly  squeezed. 
Children  willingly  do  this.  A  less  efficacious  method  is  to  lean  over  a 
jug  or  basin,  half  filled  with  hot  water.  In  this  case  the  patient  should 
not  envelop  the  head  in  a  towel,  as  many  often  do,  for  this  is  likely  to 
produce  flushing  and  headache  ;  it  is  easy  to  arrange  a  towel  around  the 
brim  of  a  jug  so  as  to  enclose  only  the  mouth  and  nose.     A  simple  dou- 


Fl"..  S.^Double-valved  Inhaler. 


ble-valved  inhaler   is  more  convenient  than   the   domestic  jug  and  very 
often  necessary. 

When  the  patient  cannot  sit  up  a  long  elastic  tube  is  necessary,  as  in 


286 


THERAPEUTICS    OF    THE    EESPIKATORY    PASSAGES. 


Hunter's  iiilialer  (see  Fig.  G),  an  improvement  on  which  is  Maw's  double- 
valved,  which  provides  a  separate  channel  for  the  expired  air. 

In  Hunter's  inhaler  the  air  is  made  to  traverse  the  water.  Bullock's 
liospital  inhaler,  and  Martindale's  portable  one  are  both  cheap  and  ef- 
fective. 


Fig.  6. — Hunter's  Inhaler. 

The  eclectic,  which  professes  to  combine  the  excellencies  of  several 
inhalers,  is  much  more  expensive,  and  some  patients  consider  it  cum- 
brous, but  it  is  very  comjDlete. 

For  any  patient  who  can  sit  up  Lee's  steam-draught  inhaler  (Fig.  3) 
is  the  least  troublesome.  It  brings  a  full  stream  of  vapor  out  at  the  end 
of  the  tube  at  a  temperature  fit  for  breathing,  so  that  no  suction  is  re- 
quired, and  no  effort  on  the  part  of  the  patient,  who  simply  sits  with  his 


Fig.  7. — Martindale's  Portable  Inhaler. 


mouth  near  the  opening  and  breathes  in  the  ordinary  way.  This  in- 
haler is  also  well  adapted  for  carbolic  acid,  as  Dr.  Lee  has  shown  that 
this  vapor  is  given  off  with  the  steam  in  a  constant  proportion. 

For  the   inhalation  of  atomized  fluids  or  sprays  a  different  method  is 
adopted.     A    pair  of  Bergson's  tubes   constitutes   the   most   important 


TOPICAL    PNEUMATICS. 


287 


part  of  the  atomizer.     They  may  be  made  of  metal,  and  with  a  hino-e,  so 
as  to  be  easily  carried    about,  as  seen  in  Fig,  9,  but  they  are  more  fre- 


FiG.  8.— The  Eclectic  Inhaler. 


quently  made  of  glass.      One    of   the  tubes  descends  vertically  into  the 
bottle  containing  the  liquid  for  atomization,  and  a  rush  of  air  or  steam 


Fig  9. — Bergson's  Portable  Tubes. 


through  the  horizontal  tube  exhausts  its  fellow,  when  the  fluid  rises 
and  is  sent  forward  in  a  fine  spray,  as  seen  in  the  following  engraving 
of  Bergson's  instrument. 


Pia.  10.— Bergson's  Atomizer, 


288  THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 

The  bottle  being  held  in  one  hand,  the  bellows  can  be  worked  with 
the  other,  or  an  assistant  may  do  this.  Wintrich  modified  the  form  of 
the  tubes  so  that  they  might  be  introduced  into  the  mouth,  and  the  spray 
thus  prevented  from  being  projected  upon  the  face. 


Fig.  11. — Wintrich's  Atomizer. 

Schnitzler's  apparatus  is  constructed  on  the  same  plan  with  a  vul- 
canite tube  protecting  the  fine  points. 

Newman's  instrument  with  glass  tubes  is  very  much  cheaper  and  quite 
as  effectual.  But  the  cheapest  of  all,  which  I  have  used  for  many  years, 
and  which  I  have  named  the  '*  Simple  Atomizer,"  is  constructed  somewhat 
differently.  The  tubes  are  placed  parallel  to  each  other,  and  the  distal 
end  of  the  upper  one  is  formed  into  a  cup  which  holds  enough  liquid  for 
each  occasion  ;  the  fluid  finds  its  way  by  gravity  to  the  point,  and  the 


Fio.  12. —  Schnitzler's  Atomizer. 


air  is  blown  through  the  lower  tube  by  the  ordinary  double  bellows  ;  the 
bottle  is  thus  dispensed  with,  and  the  apparatus  simplified.  The  tubes 
can  be  held  far  enough  in  the  mouth  to  prevent  the  spray  spreading  over 
the  face.     This  simple  atomizer   I   introduced  to    the   London  Medical 


TOPICAL    PNEUMATICS 


289 


Society  many  years  ago,  but  a  very  similar  form  seems  also  to  have  been 
used  by  Dr.  Rumbold,  and  also  by  Dr.  Solis-Cohen.  A  somewhat  modified 
form  with  a  larger  cup  has  also  been  made. 


Fig.  13. — Newman's  Atomizer. 


Instead  of  the  hand-bellows,  Dr.  Siegle  employed  steam  as  the  motive 
power,  and  the  patent  which  he  took  out  having  now  expired,  steam 
atomizers  are  made  of  various  shapes,  and  at  greatly  reduced  prices.  Fig. 
10  shows  his  instrument. 


Fig.  14. — Simple  Atomizer. 


Another  apparatus  constructed  on  the  same  principle,  with  the  addi- 
tion of  a  tube  to  convey  the  spray  to  the  mouth,  is  represented  in  Fig.  17. 
19 


290 


THERAPEUTICS    OF    THE    RESPIEATORY    PASSAGES. 


To  these  may  be  added,  when  price  is  not  an  object,  Codman  &  Shurt- 
leff's  Complete  Steam  Atomizer  (Fig.  18),  which  I  have  used  with  satis- 
faction. 

All  these  methods  of  employing  inhalations  only  permit  us  to  carry 
our  remedies  into  the  air-passages  for  a  short  period,  at  a  sitting.     ■In 


1 


Fig.  15. — Simple  Atomizer,  Large  Size. 


order  to  prolong  the  application,  or  rather  to  extend  it  over  a  long  pe- 
riod, we  have  to  resort  to  respirators  ;  but  here  another  principle  is  in- 
volved. In  using  them  we  dispense  with  the  steam,  but  we  filter  the  air 
which  the  patient  breathes,  and  not  only  so,  but  we  warm  it  as  the  stream 
of  expired  air  imparts  its  heat  to  the  respirator,  which  gives  it  up  again 
to  the  inspired  current.  A  simple  woollen  respirator  may  easily  be 
knitted  of  some  such  pattern  as  shown  in  Fig.  19  ;  and  if  the  upper  end  be 
left  open,  cotton-wool  soaked  in  antiseptics  can  be  introduced.     Or  any 


Fig.  16.— Siegle's  Atomizer. 

of  the  small  respirators  sold  in  shops  may  be  employed,  but  by  far  the 
best  is  Jeffreys',  in  which  the  air  traverses  carefully  arranged  strands  of 
gold  wire,  which  takes  and  gives  back  the  heat  from  the  breath  most 
readily,  and  maintains  a  current  of  air  of  uniform  temperature.  In  order 
to  raise  the  temperature  still  more,  Dr.   Seaton   has  proposed  [Lancet, 


TOPICAL    PNEUMATICS.  291 

1884)  to  utilize  the  body  heat,  by  compelling  the  air  to  pass  through  a 
tube  applied  to  the  surface,  but  this  would  seem  almost  necessarily  to  in- 


FiG.  17. — Atomizer  with  Tube. 


volve  greater  labor  in  breathing,  and  Jeffreys'  respirators  have  been  found 
to  regulate  the  temperature  without  much  inconvenience.     Nevertheless, 


Fig.  18. — The  Complete  Atomizer. 


the  objection  to  all  respirators  is  that  they  may  to  some  extent  impede 
the  breathing.     Dr.  Ramadge,  however,  deliberately  impeded  the  expira- 


FiG.  10. — Knitted  Respirator. 


tion  by  inserting  a  graduated  valve  for  the  purpose,  and  he  attached 
more  importance  to  the  alteration  of  pressure  thus  brought  about,  than 
to  the  inhalations  which  he  also  prescribed.     The  following  engraving 


292 


THERAPEUTICS    OF    THE    RESPIRATORY    PASSAGES. 


shows  a  combined  inhaler-respirator,  but  quite  as  frequently,  a  small  tube 
onl}"^  is  used,  with  the  necessary  valves,  so  as  to  compel  the  patient  to  ex- 
pire slowly,  leaving"  the  resoiratioii  free. 

Respirators  are  also  used  in  order  to  charge  the  air  inspired  with  anti- 
septic vapors,  and  this  method  of  treatment  has  received  a  great  im- 
petus from  Koch's  discovery  of  bacilli  in  tubercle.  If  we  can  secure  a 
])ortion  of  the  medicament  passing  into  the  air-passages,  it  is  easy  to  sup- 
pose that  it  may  produce  a  favorable  influence,  even  although  it  is  unable 


Fig  20. — Inhaler-Respirator. 

to  destroy  bacilli  or  to  repair  organic  mischief  in  the  lungs.  We  are  not, 
therefore,  shut  up  to  the  theory  that  only  germicides  can  be  useful  in 
this  way.  Dr.  Coghill's  antiseptic  respirator  has  been  largely  tried,  and 
he  reports  [Brit.  Med.  Journ.,  1881)  very  favorable  results  from  its  use. 
Some  modifications  of  his  original  form  have  been  made  by  Dr.  Hunter 
Mackenzie,  whose  instrument  has  the  disadvantage  of  being  much  heavier; 
and  by  Dr.  Roberts,  but  they  all  very  much  resemble  Fig.  21. 

Dr.  Hassall  has  investigated  the  question  how  far  the  antiseptic  sub- 
stances usually  employed  can  be  recovered  from  the  sponge  or  cotton- 
wool with  which  these  inhalers  are  charged.  He  found  [Lancet^  1883) 
that  after  one  or  two  hours'  inhalation  he  was  able  to  recover  more  than 
four-fifths  of  the  creasote,  carbolic  acid,  or  thymol  which  had  been  placed 
in  the  respirator,  from  which  he  concludes  that  most  of  the  oral  and  oro- 
nasal  inhalers  are  of  little  use,  and  he  has  devised  others  in  which  the 
antiseptic  substance  is  distributed  over  a  much  larger  extent  of  surface. 


TOPICAL    PNEUMATICS.  2^3 

Our  view  of  the  value  of  antiseptic  respirators  must  depend  somewhat 
on  the  intention  with  which  we  use  them.  If  we  wish  merely  to  intro- 
duce a  certain  amount  of  vapor  into  the  respiratory  passages  this  can  be 
accomplished  by  very  simple  means.  A  glass  tube  containing  some  of 
the  substance  on  cotton-wool  or  sponge  will  answer  the  purpose,  and 
such  a  simple  tube  packed  with  blotting-paper  has  lately  been  sold  as  the 
"  patent  pocket  inhaler,"  though  why  it  should  be  patented  must  be  a 
mystery  to  those  who  have  used  it  many  years  before  ;  perhaps  the  pat- 
entee relies  upon  the  shape  of  his  blotting-paper.  A  vapor  may  be  intro- 
duced either  through  the  nose  or  mouth,  and  a  Frankfort  physician  a 
few  years  ago  contrived  the  simplest  possible  nasal  inhaler,  the  advan- 
tage of  which  he  held  to  be  its  invisibility.  It  was,  in  fact,  a  small  cellu- 
loid tube,  which  was  to  be  passed  into  the  nostril  and  then  a  piece  of 


Fig.  21.— The  Antiseptic  Respirator. 


cotton-wool  charged  with  the  antiseptic  introduced,  the  tube  merely 
serving  to  protect  the  lining  of  the  nostril.  Dr.  Ward  Cousins  has  lately 
proposed  {Lancet,  1884)  a  somewhat  larger  tube,  the  end  of  which  can  be 
placed  either  in  the  nostril  or  mouth  and  supported  by  a  wire  which  sus- 
pends the  inhaler  and  compresses  the  nose.  He  considers  it  useful  not 
only  for  introducing  antiseptic  vapor  but  as  a  mechanical  method  of  sus- 
taining forced  inspiration.  Dr.  Burney  Yeo  recommends  a  small  respira- 
tor of  perforated  zinc  {Brit.  Med.  Joiirn.,  1884). 

If  we  wish  to  compel  a  patient  to  breathe  a  pure  atmosphere  and  at- 
tempt to  attain  this  end  by  means  of  a  respirator,  it  is  obvious  that  an 
oro-nasal  one  would  be  preferable  and  that  it  must  be  such  an  one  as  does 
not  impede  respiration,  since  it  would  have  to  be  constantly  worn.  On 
the  other  hand,  if  the  object  were  only  to  kill  bacilli  believed  to  be  pres- 
ent, it  would  be  necessary  for  the  antiseptic  to  be  sufficiently  noxious  to 
these  organisms  and  yet  not  poisonous  to  the  patient,  and  if  such  a 
o-ermicide  could  be  found  it  need  only  be  breathed  for  a  sufficient  time  to 


294:  THERAPEUTICS    OF   THE    EESPIRATORY    PASSAGES. 

accomplish  this  object.  Again,  if  we  only  wish  to  act  upon  the  respira- 
tory membrane  or  the  lungs  in  the  same  way  as  when  we  employ  steam 
inhalations,  then  it  would  suffice  for  the  respirator  to  be  charged  with  a 
volatile  medicament  of  such  a  strength  as  should  be  found  sufficient,  and 
for  the  instrument  to  be  worn  for  a  short  time  at  suitable  intervals.  Fur- 
ther, if  we  abandon  these  efforts  and  revert  to  the  use  of  respirators  for 
the  purpose  of  partially  filtering  and  warming  the  air,  then  the  instru- 
ment must  be  regarded  rather  in  the  light  of  protective  clothing  and  the 
times  at  which  it  is  worn  regulated  accordingly.  Even  in  this  case  it  is 
most  important  that  the  respirator  should  not  impede  inspiration,  or  the 
patient  will  soon  give  up  its  use.  Heavy  instruments  are  apt  to  cause  a 
feeling  of  oppression,  even  when  sufficient  provision  is  made  for  the  pass- 
age of  air,  a  point  often  overlooked.  Those  which  press  closely  on  the 
face  are  found  to  be  very  irksome,  and  it  is  essential  that  a  patient  should 
be  able  to  take  sufficient  exercise  without  experiencing  any  difficulty  or 
oppression  of  his  breathing.  It  seems  obvious,  therefore,  that  the  sim- 
pler and  lighter  the  instrument  the  better.  Those  which  are  complex 
and  cumbrous  are  sure  to  be  discarded. 


Uses  of  Inhalations  and  Other  Topical  Pneumatics. 

Though  we  have  considered  inhalations  as  topical  remedies  for  the 
entire  respiratory  passages,  it  must  not  be  forgotten  that  the  absorptive 
power  of  the  membrane  is  such  that  many  of  them  become  the  most  po- 
tent and  rapid  of  general  remedies.  It  is,  therefore,  only  as  a  matter  of 
convenience  that  they  have  been  included  in  this  chaptei'.  The  anaes- 
thetics and  nitrite  of  amyl  are  examples  of  this.  Then,  again,  the  inhala- 
tion of  oxygen  can  only  be  regarded  as  a  general,  not  a  local  remedy.  But 
in  most  other  cases  the  topical  effect  is  so  important  as  to  obtain  the  first 
consideration. 

Steam  inhalations  may  be  considered  first.  The  contact  of  simple 
watery  vapor  with  inflamed  mucous  membrane  is  so  grateful  as  to  de- 
serve to  be  called  anodyne.  It  cuts  short  the  congestive  stage  of  catarrh 
by  supplying  moisture,  and  so  relieving  the  dryness,  heat,  and  oppres- 
sion, and  at  a  later  stage  it  dilutes  and  assists  the  removal  of  the  secre- 
tion. In  acute  bronchitis  the  inhalation  of  steam  is  often  of  the  greatest 
service,  and  the  vapor  may  be  made  the  purveyor  of  other  volatile  reme- 
dies, either  anodyne  or  stimulant.  Much  of  the  good  effect  of  many  in- 
halations may  be  traced  to  the  influence  of  the  steam.  In  croup  and 
diphtheria,  great  good  arises  from  keeping  the  atmosphere  of  the  sick- 
room saturated  with  steam.  In  the  first  edition  of  my  "  Sore  Throat "  I 
insisted  on  the  value  of  a  more  thorough  and  systematic  use  of  steam  in 
these  diseases,  and  have  been  advocating  it  ever  since.     During  the  last 


TOPICAL    PNEUMATICS.  295 

few  years  it  has  also  been  recommended  by  Oertel  and  other  German 
writers. 

Any  volatile  substance  can  be  easily  employed  in  the  form  of  inhala- 
tion, and  those  herbs,  the  therapeutic  value  of  which  depends  on  an  aro- 
matic volatile  principle,  are  often  thus  used  ;  or  this  principle  is  previ- 
ously extracted,  as  in  the  case  of  essential  oils.  The  soothing  properties 
of  steam  are  often  increased  by  employing  hops — the  vapor  of  the 
freshly-made  infusion  being  charged  with  the  sedative  properties  of  the 
plant  ;  the  oil  of  hops  is  too  irritating  to  substitute  for  the  crude  drug. 
Chamomile  flowers  may  be  used  in  the  same  way.  Another  aromatic 
sedative  is  obtained  by  putting  a  teaspoonful  of  tinct.  benz.  comp.  into 
the  inhaler,  with  a  pint  of  hot  water.  Vapor  conise  is  more  distinctly 
sedative — its  efficacy  depending  on  the  conia  being  set  free  by  the  alkali, 
for  which  reason  it  should  be  added  at  the  time.  The  succus  conii  is  to 
be  preferred  to  the  extract,  as  previously  pointed  out.  The  vapor  acidi 
hydrocyanici  is  employed  with  cold  water,  but  may  be  ranked  among 
sedatives.  The  volatile  parts  of  opium  can  be  utilized  by  putting  the 
tincture  or  the  solid  drug  in  the  inhaler  with  hot  water.  Ether  and 
chloroform  may  be  used  with  water  at  a  low  temperature.  Conium  or 
opium,  in  combination  with  chloroform  and  similar  compound  inhala- 
tions will  often  prove  of  service  when  a  simple  one  fails.  It  is,  however, 
obvious  that  very  volatile  substances  may  be  as  well  administered  with- 
out the  medium  of  water.  A  very  simple  inhaler,  or  a  little  cotton-wool 
in  a  cone  of  paper,  will  suffice  for  chloroform,  ether,  and  nitrite  of  amyl. 

Besides  anodyne  inhalations,  those  possessing  stimulant  properties 
are  most  important.  In  the  British  Pharmacopoeia  there  are  only  three 
— vapor  chlori,  creasoti,  and  iodi.  The  mode  of  using  differs  in  each 
case,  while  each  vapor  is  a  special  stimulant.  For  vapor  chlori  cold  water 
is  used  ;  for  vapor  iodi  the  water  is  heated  after  the  addition  of  the 
tincture,  but  the  other  plan  is  quite  effectual.  Camphor  is  a  good 
stimulant  for  inhalation.  Ten  drops  of  the  spirit  may  be  put  into  the 
inhaler  to  begin  with  :  it  is  better  to  dilute  it  with  more  spirit.  Cam- 
phor is  also  a  very  useful  addition  to  many  other  inhalations.  In  like 
manner  most  of  the  essential  oils  can  be  used  as  stimulants.  They  can 
be  dissolved  in  spirit  or  diffused  through  water  by  means  of  magnesia,  or 
powdered  silex,  in  the  manner  often  resorted  to  for  making  medicinal 
waters.  The  oils  of  aniseed,  cajeput,  cloves,  cinnamon,  marjoram,  myrtle, 
rosemary,  and  others  are  adapted  for  this  purpose.  Ammonia  is  a  gen- 
eral stimulant  often  resorted  to,  and  may  be  utilized  for  its  local  effect. 

When  the  effect  of  steam  is  not  needed,  we  may  try  the  plan  recom- 
mended by  the  late  Dr.  J.  A.  Symonds,'  viz.:  inhaling  solutions  of 
balsams  in   ether,  or  pyro-acetic  spirit   from  an  ordinary  wide-mouthed 

'  British  Medical  Journal,  1868. 


296  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

bottle,  the  warmth  of  the  hand  holdidg  it  being  quite  sufficient  to  vola- 
tilize the  liquid.  I  prefer  ether  to  the  pyro-acetic  spirit.  Spirit  of 
chloroform  may  also  be  used  by  this  method.  Half  an  ounce  of  benzoic 
acid  in  an  ounce  of  ether  forms  a  standard  solution,  to  which  two  drachms 
of  balsam  of  Peru,  or  of  Tolu,  or  of  any  similar  substance,  may  be  added. 
Turpentine  has  also  been  used  in  this  way,  but  might  then  be  made  the 
menstruum.  Other  rather  volatile  drugs,  such  as  creasote,  carbolic  acid, 
iodine,  the  essential  oils,  etc.,  can,  if  desired,  be  employed  in  this  manner 
without  steam,  but  very  often  the  warm  vapor  is  an  important  element 
in  the  treatment. 

Sometimes  warm  inhalations  are  not  desirable.  We  can  then  use 
sprays  or  atomized  fluids.  Sprays  are  generally  useful  when  it  is  an  ad- 
vantage to  administer  the  inhalations  at  a  low  temperature  ;  while  for 
warm  applications  I  mostly  resort  to  the  mode  of  inhaling  steam  impreg- 
nated with  the  remedy.  It  is  usually  advisable  to  administer  astringent 
sprays  cold,  though,  of  course,  they  may  be  used  warm.  Anodynes  are 
applicable  either  w'ay,  but  more  frequently  should  be  taken  warm. 
After  warm  inhalations  it  is  often  desirable  for  the  patient  not  to  go 
into  the  open  air,  or  into  a  cold  room  ;  but  the  cold  spray  is  the  best 
possible  preparation  for  such  sudden  changes  of  temperature. 

The  remedies  most  commonly  used  in  the  atomizer  are  solutions  of  metal- 
lic salts.  As  astringents,  sulphate  and  chloride  of  zinc,  alum,  perchloride 
of  iron,  and  sulphate  of  iron.  The  strength  of  the  solutions  of  these 
salts  may  vary  from  two  to  ten  grains  in  the  ounce,  or  more,  according 
to  circumstances.  Permanganate  of  potash,  one  to  five  grains  per  ounce, 
is  disinfectant  and  stimulant,  and  in  some  cases  exercises  a  most  happy 
influence  on  mucous  membranes.  In  other  cases  calx  chlorata,  two  to 
five  grains,  is  preferable  ;  or  we  may  use  the  liq.  calcis  chlorate,  or  the 
Hq.  sodae  chlor.,  ten  to  sixty  minims,  or  liq.  chlori.,  two  to  thirty  min- 
ims per  ounce.  Carbolic  acid,  one  to  five  grains,  is  a  good  stimulant, 
particularly  when  the  membrane  is  unusually  dry.  This  remedy  is  also 
much  used  as  an  antiseptic  and  disinfectant  in  various  conditions  of  the 
membrane.  A  much  weaker  solution  thus  is  required,  for  this  also  ex- 
ercises a  soothing  influence  in  cases  of  great  irritability.  It  is  not  to  be 
forgotten  that  carbolic  acid  is  readily  absorbed  by  mucous  membranes. 
Lactic  acid  has  been  strongly  recommended  as  a  solvent  of  the  false 
membrane  of  diphtheria.  About  half  a  drachm  in  the  ounce  will  be 
strong  enough  generally,  but  I  have  had  occasion  to  use  it  much  more 
concentrated.  Nitrate  of  alumina  (two  to  five  grains)  was  tried  by  the 
late  Dr.  Beigel,'  who  also  used  many  other  substances,  including  acetate 
of  lead,  chloride  of  sodium,  and  even  cod-liver  oil.  I  have  used  chloride 
of  aluminium  rather  freely  as  an  astringent. 

'  On  luLalation.     London,  1866. 


TOPICAL    PNEUMATICS.  297 

As  an  anaesthetic  bromide  of  potassium  has  been  used,  ten  to  fifteen 
grains  ;  but  weaker  solutions  are  serviceable  for  other  purposes.  Solu- 
tions of  the  alkaline  carbonates  and  tlieir  salts  form  a  very  useful  series. 
Thus,  the  carbonates  of  soda,  potash,  or  lithia  may  be  tried,  two  to  ten 
grains.  Muriate  of  ammonia,  eight  to  fifteen,  is  reputed  to  possess  pecul- 
iar effects  on  the  faucial  membrane.  The  local  influence  of  chlorate  of 
potash,  now  fully  recognized,  may  be  obtained  in  this  way,  two  to  ten 
grains.  A  number  of  mineral  waters  are  also  used  as  sprays.  Those 
containing  sulphur,  or  chloride  of  sodium  are  most  in  repute.  Corrosive 
sublimate  is  sometimes  used  in  specific  cases,  but  such  remedies  should 
only  be  used  with  circumspection. 

Demarquay  recommends  glycerine  to  soothe  an  irritated  pharynx,  and 
the  late  Dr.  Scott  Alison  employed  this  fluid  in  laryngitis  and  tracheitis. 
Laudanum  and  solution  of  the  salts  of  morphia  can  be  used  in  the  form 
of  spray,  five  minims  to  twenty  at  a  time,  properly  diluted  ;  so  can  the 
tinctures  of  h_yoscyamus,  conium,  belladonna,  etc.  In  asthma,  success 
seems  to  have  followed  Fowler's  solution,  five  minims  at  a  time,  adminis- 
tered in  this  manner.  Recently  Professor  See  has  recommended  sprays 
of  iodide  of  potassium  in  this  disease.  Other  uses  for  "this  drug  will  occur 
to  the  reader,  and  solutions  of  iodine  have  also  been  used.  Sprays  of 
vin.  ipecac,  have  of  late  years  come  into  use  and  sometimes  seem  very 
efficient,  but  to  many  patients  they  are  extremely  disagreeable.  Sul- 
phurous acid  is  generally  prescribed  too  diluted.  It  may  be  employed 
pure,  as  advised  by  Dewar  *  and  Pairman,''  or  it  may  be  diluted  with 
one,  two,  or  three  parts  of  water.  It  should  be  recently  prepared.  Tan- 
nin, as  an  astringent,  varies  much  in  the  dose,  and  is  often  given  too 
weak  to  be  effectual.  According  to  the  effect  required  the  strength 
may  vary  from    a   single  grain   per  ounce    to  fifteen  or  more. 

Iodoform  has  been  used  as  a  spray  as  well  as  in  other  modes.  Profes- 
sor Sormani  contrived  a  special  apparatus  for  the  purpose  of  experiment- 
ing upon  animals,  and  by  means  of  compressed  air  he  forced  an  ethereal 
solution  of  iodoform  deep  into  the  lungs,  in  order  to  determine  its  power 
as  an  antiparasitic  in  phthisis.  That  the  remedy  was  thus  carried  into 
the  air-cells  he  proved  experimentally  ;  he  has  also  reported  three  cases 
of  phthisis  treated  by  iodoform  sprays.  The  patients  gained  in  weight  and 
some  of  the  symptoms  were  relieved  but  the  expectoration  continued  to 
contain  bacilli,  though  their  number  diminished.  The  expectoration  in- 
jected into  guinea-pigs  was  still  infective,  but  seemed  to  be  rather  less 
virulent.  Other  attempts  are  being  made  to  bring  antiseptics  to  bear  in 
the  treatment  of  lung  diseases  by  inhalation. 


1  On  the  Application  of  Sulphurous  Acid   to  the  Prevention  and  Cure  of   Conta- 
gious Diseases.     1867. 

2  The  Great  Sulphur  Cure  brought  to  the  Test.     1868. 


298  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

So  far  we  have  been  considering  those  topical  remedies  which  oper- 
ate on  the  whole  of  the  respiratory  passages  at  once.  It  may,  of  course, 
be  desirable,  even  for  a  disease  which  only  involves  a  portion  of  the  mu- 
cous membrane,  to  subject  it  all  to  the  action  of  remedies  ;  but  there  are 
other  cases  in  wiiich  we  may  wish  to  restrict  the  extent  of  the  applica- 
tion. And  then,  again,  there  are  remedies  which  only  affect  a  small  por- 
tion of  the  surface,  and  some  of  which  we  must  now  notice. 

Sprays  may  very  easily  be  localized  and  for  this  reason  may  claim  a 
place  between  vapors  and  liquids  ;  but  enough  has  been  said  about  them 
and  we  pass  on  to  the  latter,  beginning  with 

Gargles. — This  form  of  local  remedy  is  very  ancient  and  was  freely 
used  by  Hippocrates.  It  is  still  popular,  though  considerable  discussion 
has  at  times  taken  place  as  to  its  value.  While  some  physicians  have 
almost  excluded  gargles  from  their  practice,  others  have  relied  upon 
them  to  a  great  extent.  The  former  have  maintained  that  they  never 
come  in  contact  with  more  than  the  anterior  surface  of  the  velum  and 
uvula,  and  perhaps  a  portion  of  the  tonsils.  The  latter  have  endeavored 
to  show  that  they  penetrate  much  farther.  Even  were  the  first  allegation 
correct  there  would  still  be  a  use  for  gargles,  but  it  is  now  generally 
abandoned. 

These  diverse  views  have  no  doubt  partly  depended  on  the  inclusion 
of  several  distinct  acts  in  the  term  gargling.  A  mere  mouth-wash  may 
be  so  employed  that  the  anterior  surface  of  the  velum  is  subjected  to  its 
influence.  The  word  gargling,  however,  is  generally  understood  to  imply 
that  the  air  is  to  be  expelled  through  the  liquid  with  sufficient  force  to 
make  the  bubbling  '  noise  which  many  seem  to  consider  so  essential  to 
the  process.  But  a  moment's  thought  will  suffice  to  show  that  the  liquid 
may  be  permitted  to  remain  in  the  position  it  occupies  as  long  as  the 
breath  can  be  held  and,  further,  that  expiration  may  be  carried  on  so 
gently  as  to  prevent  any  bubbling  noise  being  heard.  If  now  any  at- 
tempt be  made  either  to  swallow  or  to  inspire  to  a  very  slight  degree, 
the  liquid  may  pass  farther  and  yet  be  arrested  before  it  sets  up  any 
spasmodic  action.  The  act  of  gargling  may  be  well  studied  in  conjunc- 
tion with  that  of  swallowing,  and  the  reader  will  no  doubt  be  aware  of 
the  diversities  of  opinion  that  have  prevailed  respecting  the  physiology 
of  deglutition.  We  all  know  that  soft  bodies  produce  little  irritation  in 
the  larynx  compared  with  hard  ones,  though,  as  previously  pointed  out,  a 
drop  or  two  of  liquid  coming  unexpectedly  on  certain  parts  may  at  once 
set  up  spasm. 

It  is  believed  by  many  that  the  use  of  the  epiglottis  in  closing  the  air- 

'  Gargle  and  gurgle  were  originally  the  same  word — both  forms  are  derived  from 
the  Latin  c/urgulio,  throat,  and  this  doubtless  from  the  older  Greek,  yapyapfwv.  The 
reduplicated  syllable  gargar  also  appears  with  the  same  meaning  in  Hebrew  and  other 
oriental  languages. 


TOPICAL    PNEUMATICS.  299 

passage  during  deglutition  has  been  somewhat  exaggerated.  Certainly  I 
have  met  with  many  cases  in  which  great  destruction  of  the  epiglottis 
had  occurred — some  in  which  it  had  been  entirely  destroyed — without  the 
power  of  swallowing  being  greatly  affected.  On  the  other  hand,  we  con- 
stantly see  swelling  and  ulceration  of  the  epiglottis  associated  with  pain 
and  difficulty  in  deglutition. 

M.  Krishaber  having  masticated  and  insalivated  a  little  bread  crumb, 
pushed  it  with  his  finger  over  the  edge  of  the  epiglottis,  and  then  by  an 
inspiration  drew  it  into  the  air-passage,  expelling  it  again  by  a  sudden 
forcible  expiration.  M.  Guinier,  of  Montpellier,'  had  previously  ob- 
served on  himself,  by  means  of  the  mirror,  that  such  a  morsel  of  soft 
bread  could  come  upon  the  closed  glottis  without  causing  any  uneasiness. 
The  last-named  author  subsequently  attained  such  command  over  the 
parts  as  to  let  liquids  enter  the  larynx,  and  founded  upon  his  experience 
the  plan  of  laryngeal  gargling."  "We  must  remember,  however,  that 
the  presence  of  the  mirror  in  the  throat  during  an  effort  to  swallow  com- 
pletely changes  the  conditions  to  be  studied.  In  the  natural  act  of  deg- 
lutition there  can  be  little  doubt  that  the  air-passage  is  generally  closed. 
The  impossibility  of  breathing  during  that  act,  and  the  spasm  excited  by 
the  entrance  of  small  quantities  of  the  food  or  drink,  seem  to  show  this. 
Besides,  if  we  eat  any  substance  that  will  impart  a  distinct  color  to  the 
membrane  over  which  it  passes,  and  then  practise  autolaryngoscopy,  we 
find  that  it  discolors  the  anterior  surface  of  the  epiglottis,  but  not  the 
posterior,  still  less  the  mucous  membrane  of  the  vestibule  of  the  larynx. 

From  w'hat  has  preceded  it  will  be  readily  understood  that  the  act  of 
gargling  may  varv  very  much  with  the  individual.  Accordingly,  we  find 
tiiat  some  persons  never  learn  to  gargle  properly,  while  others  achieve 
what  at  first  seems  impossible.  Singers  generally  acquire  considerable 
control  over  the  parts,  while  those  who  have  never  learned  to  gargle 
sometimes  find  it  no  easy  task.  The  majority  of  patients,  in  point  of 
fact,  require  some  instruction  respecting  the  end  to  be  attained.  In  using 
a  mouth-wash  the  velum  and  uvula  descend  so  as  to  cut  off  all  communi- 
cation with  the  pharynx.  In  gargling,  as  frequently  understood,  the  re- 
sult may  be  almost  the  same,  the  liquid  coming  in  contact  with  the  ante- 
rior surface  of  the  velum  and  uvula  only.  If,  however,  the  patient  should 
now  raise  the  velum,  as  many  can  do,  some  of  the  liquid  will  flow  into  the 
pharynx.  There  it  produces  a  desire  to  swallow,  and  unless  the  patient 
can  control  this  some  of  it  will  pass  into  the  oesophagus  and  stomach. 
Some  persons,  however,  instead  of  yielding  to  the  desire  to  swallow,  sud- 
denly jerk  the  head  forward,  and  a  quick,  forcible  expiration  taking  place 


'  Noiivelles  Experiences  sur  la  Deglutition  faites  au  moyen  *de   1' Auto-Laryngo- 
scope (L' Union  Med.,  1865). 

*  Etude  du  Gargarism  Laryngien.     Paris,  ISfiS. 


300  THERAPEUTICS    OP    THE    RESPIRATOKY    PASSAGES. 

at  the  same  rnotnent  the  liquid  is  expelled  through  the  nose.  "What  they 
do  involuntarily  can  be  accomplished  by  others  deliberately  and  without 
inconvenience.  In  persons  possessing  this  control  over  the  parts  we  may 
often  obtain  good  results  from  a  natural  nasal  douche  thus  employed. 

Is  is  by  no  means  so  easy  to  let  the  liquid  enter  the  larynx,  and,  in 
spite  of  persistent  efforts,  many  will  totally  fail  in  the  attempt.  Of 
course,  the  glottis  must  be  kept  closed  if  the  fluid  is  to  rest  upon  it,  and 
therefore  the  duration  can  only  be  while  the  patient  can  hold  his  breath. 
M.  Guinier,  wlio  has  demonstrated  his  method  with  the  laryngoscope, 
says  that  the  head  should  not  be  thrown  back,  as  the  less  it  is  raised  the 
less  urgent  is  the  desire  to  swallow.  He  also  advises  that  the  mouth 
should  not  be  quite  closed.  With  these  precautions  he  takes  the  liquid 
into  the  mouth,  brings  forward  the  lower  jaw,  and  closes  the  glottis  by 
the  uncompleted  act  of  emitting  a  vowel  sound.  The  velum  in  this  dis- 
position of  the  parts  is  raised,  and  the  base  of  the  tongue  perhaps  falls  a 
little,  so  that  the  liquid  finds  its  way  into  the  larynx,  where,  if  the  patient 
can  completely  control  the  sensibility,  it  may  remain  as  long  as  the  breath 
is  held.  The  slightest  attempt  to  inspire  will  bring  on  spasmodic  cough. 
Only  the  few  can  expect  to  attain  success  in  this  method,  and  its  use  is 
therefore  very  restricted,  especially  when  we  remember  that  there  are 
other  modes  of  applying  liquids  to  the  laryngeal  mucous  membrane. 

In  gargling  it  is  more  important  to  manage  the  respiration  than  deg- 
lutition. If  compelled  to  swallow,  the  patient  merely  receives  a  little  of 
the  fluid  in  his  stomach,  and,  unless  the  gargle  should  contain  some  nox- 
ious ingredient,  there  is  an  end  of  the  incident.  On  the  other  hand,  en- 
trance of  the  fluid  into  the  air-passages  may  give  rise  to  severe  lar^'ngeal 
spasm. 

Astringents,  disinfectants,  and  antiseptics  are  the  remedies  most  fre- 
quently required  in  this  form,  but  anodynes  may  be  utilized  in  the  same 
wav.  One  of  the  best  gargles  is  a  solution  of  alum,  the  strength  of 
which  may  be  vai'ied  according  to  the  effect  required.  Chloride  or  nitrate 
of  aluminium  may  be  employed  for  the  same  purposes.  For  a  powerful 
astringent  tannin  may  also  be  used — one  or  two  drachms  in  half  a  pint  of 
water,  to  which  a  drachm  of  rectified  spirit  or  an  ounce  of  g-lycerine  has 
been  added.  Borax  and  chlorate  of  potash  are  also  useful  as  both  gargles 
and  mouth-washes.  The  former  is  slightly  alkaline  as  well  as  astringent  ; 
the  latter  possesses  special  value  in  an  aphthous  condition  of  the  buccal 
and  faucial  mucous  membrane,  and  is  often  advantageously  combined 
with  decoction  of  bark.  As  a  disinfecting  wash  and  gargle  Condy's  fluid 
is  the  best,  but  chlorated  gargles  are  also  valuable.  Carbolic  acid  is  a 
good  stimulant  to  the  pharyngeal  mucous  membrane,  but  its  flavor  is 
very  disagreeable  to  some  patients.  Weak  gargles  of  carbolic  acid  are 
not  merely  slight  stimulants,  but  exercise  a  soothing  influence  over  irri- 
table mucous  membrane.     The  sulpho-carbolates  are  also  useful.     I  have 


TOPICAL    PNEUMATICS. 


;^oi 


had  excellent  results  from  lactic  acid,  both  as  a  gargle  and  in  the  form  of 
spray.  Three  or  four  drachms  or  more  may  be  diluted  with  eight  or  ten 
ounces  of  water.  This  remedy  is  of  special  value  in  diphtheria.  The 
lactates  and  lime-water  are  also  used  in  the  same  disease.  Mineral  acids 
ought  not  to  be  employed  as  gargles,  as  they  destroy  the  patient's  teeth, 
and  less  injurious  substances  are  equally  or  more  efficacious. 

It  is  obvious  that  it  is  not  desirable  to  order  gargles  for  children  who 
have  not  learned  to  use  them,  or  for  per- 
sons whose  fauces  are  so  inflamed  as  to 
make  all  movements  of  these  parts  pain- 
ful. 

Gargles  are  usually  employed  cold, 
but  occasionally — especially  when  ano- 
dyne— they  are  ordered  warm. 

The  nasal  douche  may  be  mentioned 
here,  inasmuch  as  it  is  in  one  sense  sup- 
plementary to  gargling.  By  it  the  fluid 
is  brought  into  contact  with  a  portion  of 
raucous  membrane  which,  in  the  major- 
ity of  persons,  is  otherwise  inaccessible 
to  local  treatment  such  as  the  patient  can  *''°-  22.-Siphon  Douche, 

employ.  I  usually  recommend  the  simple  siphon  douche,  Fig.  22.  The 
nasal  douche  is,  of  course,  most  serviceable  when  the  disease  is  located 
in  the  posterior  nares,'  but  is  also  of  value  in  some  laryngeal  cases. 
The  liquids  most  serviceable  for  the  nasal  douche  are  weak  saline  and 
alkaline  solutions.  Half  a  drachm  of  carbonate  of  soda  in  a  pint  of 
water  is  one  of  the  best  forms,  being  both  safer  and  more  agreeable  than 
the  chloride  of  sodium  so  often  prescribed.  By  this  the  mucous  mem- 
brane may  always  be  thoroughly  freed  from  the  discharges,  and  thus 
prepq*ed  for  other  remedies.  Astringents  may  be  afterward  resorted  to 
in  many  cases,  the  chlorides  of  aluminium,  zinc,  and  iron  being  employed 
in  very  small  quantity.  The  sulpho-carbolate  of  zinc  is  a  good  astrin- 
gent. The  permanganates  are  still  more  useful,  possessing  local  action 
and  being  deodorizers.  Chloride  of  lime  I  have  also  found  very  valu- 
able. Carbolic  acid  has  also  most  valuable  properties  and  is  a  recognized 
disinfectant.  The  nasal  douche  should  be  used  tepid  at  first  in  all  cases. 
Occasionally  it  may  be  desirable  to  decrease  the  temperature,  especially 
when  astringents  are  employed,  A  temperature  of  85°  Fahr.  may  then 
be  employed,  and  gradually  reduced  to  75°,  or  even  70°.  Very  rarely  do 
we    descend    to    the   ordinary  cold  water.     The  patient   should   breathe 


'  See  the  author's  paper  on  Ozsena,  read  before  the  Medical  ^Society  of  London, 
October  20,  1871  (Medical  Press  and  Circular,  December  6,  1871).  Reference  may  al- 
so be  made  to  the  author's  contribution  to  the  same  journal  on  Syphilitic  Diseases  of 
the  Throat  (January  10  and  February  28,  1872). 


302  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

quietly  and  restrain  any  movement  of  deglutition,  in  order  that  the 
Eustachian  tubes  may  remain  closed.  It  can  no  longer  be  doubted  that 
in  using  a  nasal  douche  the  accidental  entrance  of  fluid  into  the  ear  has 
given  rise  to  serious  results.  It  is  not  necessary  to  have  much  pressure — 
just  enough  to  cause  the  fluid  to  flow  through  the  nares  will  sufTice,  and 
this  will  be  produced  with  the  siphon  douche,  when  the  vessel  is  not 
raised  much  above  the  patient's  head.  It  is  a  good  plan  for  the  patient 
at  first  to  hold  it  himself — he  will  scarcely  then  be  able  to  lift  it  too 
high.  The  soda  solution  above  named  is  the  best  for  removing  hardened 
secretions.  I  have  also  found  it  less  irritant  than  the  salt  solution  so 
constantly  used,  and  Weber-Liel  '  has  shown  that  it  is  less  likely  to 
injure  the  ear — a  conclusion  ^uite  in  accordance  with  my  experience.  A 
weak  saline  produces  less  stuffiness  than  pure  water.  In  using  astrin- 
gents care  should  be  observed  to  use  them  Aveak  enough.  Half  a  grain 
per  ounce  of  sulphate  or  acetate  of  zinc  is  quite  enough.  More  is 
apt  to  give  rise  to  headache,  local  irritation,  and  other  unpleasantness. 
Alum  is  said  to  have  impaired  the  function  of  smell.  The  douche  should 
be  used  once  or  twice  a  day — seldom  oftener,  but  it  is  necessary  in  many 
cases  to  continue  it  for  a  long  time. 

Irrigations. — I  have  designed  tubes  with  perforated  extremities,  by 
means  of  which  the  nasal  passage  can  be  carefully  irrigated  by  the  physi- 
cian, both  from  the  front  and  back.  In  this  way  we  may  apply  fluid 
remedies  which  should  not  be  entrusted  to  the  patient. 

Syringes  and  atomizers  constructed  for  the  purpose  can  also  be  used 
to  convey  medicated  fluids  to  the  nasal  passages.  Besides  these  methods 
we  may  sometimes  avail  ourselves  of  the  more  primitive  plan  of  snuffing 
up  the  liquid  by  a  series  of  sudden  short  inspirations.  Fluids  may  thus 
be  taken  up  from  the  hollow  of  the  hand  or  from  a  convenient  vessel. 
Some  persons  acquire  a  trick  of  this  kind,  and  call  it  "  drinking  through 
the  nose." 

The  Pharyngeal  Douche  and  Irrigator. — It  is  easy  to  direct  a  stream 
of  liquid  on  the  posterior  wall  of  the  pharynx.  For  this  purpose  I  have 
arranged  mouth-pieces  which  can  be  used  in  place  of  the  nose-piece  of  the 
nasal  douche.  Some  patients  learn  to  employ  this  method  themselves. 
The  liquids  are  such  as  have  been  recommended  for  the  nasal  douche, 
and  for  gargles,  but  their  strength  should  be  between  these  two. 

My  phar3'ngeal  irrigator^  like  its  nasal  fellow,  consists  of  a  properly 
shaped  silver  tube  perforated  at  the  extremity  by  numerous  minute  holes, 
so  that  the  liquid  can  be  projected  in  a  fine  shower  by  means  of  a  small 
Higginson's  syringe  attached  to  it.  The  atomizer  may  be  resorted  to 
when  it  is  desirable  to  break  up  the  fluid  into  a  fine  spra}^,  but  both  the 
pharj'ngeal  and  nasal  irrigators  will  often  be  found  of  service. 

'  Berliner  klin.  Woch.,  April  1,  1878. 


TOPICAL   PNEUMATICS.  303 

Linctus. — In  order  to  somewhat  prolong  the  local  action  of  medicines 
which  are  to  be  swallowed  they  may  be  rendered  thicker  and  more  glu- 
tinous by  sugar  and  other  additions.  We  then  have  the  linctus,  loch  or 
lohoch,  called  also  eclegma,  eclectos,  ecleitos,  elegma,  and  illinctus — va- 
rious terms  derived  from  €KXei;^w.  Various  syrups  and  mucilages  may  be 
used  for  the  same  qualities,  or  may  enter  into  the  composition  of  the 
linctus.  Glycerine,  from  its  slowness  to  evaporate,  may  be  used  to  attain 
the  same  end,  and  is,  indeed,  rather  too  popular,  for  since  the  glycerine 
of  tannin  and  borax  were  introduced  to  the  Pharmacopoeia  their  use  has 
become  quite  an  abuse. 

'  Solids. 

As  sprays  take  an  intermediate  place  between  vapors  and  liquids 
so  between  these  and  solids  we  might  place  confections  or  electuaries, 
in  which  we  have  a  tenacious  semi-solid  substance,  which  may  be  slowly 
dissolved  in  the  mouth,  and  thus  the  local  action  of  its  ingredients  pro- 
longed ;  though  these  preparations  are  also  used  as  vehicles  for  system- 
ic remedies.  In  confectio  opii  the  galena,  mithridate,  philonium,  and 
theriaca  of  antique  pharmacy  survive. 

Lozenges,  being  completely  solid,  are  slower  of  solution,  and  there- 
fore enable  the  medicament  to  exercise  a  much  more  prolonged  influ- 
ence in  the  mouth  and  fauces,  and  have  always  been  popular  remedies. 
The  Greek  hypoglottides  are  represented  in  our  lozenges.  Although  the 
London  and  Dublin  Pharmacopoeias  omitted  them,  the  Edinburgh  re- 
tained them,  and  the  British  has  restored  them.  In  doing  so,  however, 
the  lozenge  has  been  made  as  much  use  of  as  a  vehicle  as  for  local  ef- 
fects. Thus  some  officinal  lozenges  (as  morphia  and  iron)  are  chiefly  to 
be  regarded  as  dosed,  general  remedies,  though  others  (as  tannin  and 
chlorate  of  potash)  are  valuable  for  their  topical  influence.  It  is  obvi- 
ous that  the  two  qualities  may  often  be  combined. 

For  special  topical  use  lozenges  should  possess  the  following  quali- 
ties :  1.  They  should  dissolve  slowly  in  the  mouth,  so  that  the  resulting 
solution  of  the  medicament  may  remain  as  long  as  possible  in  contact  with 
the  mucous  membrane.  2,  They  should  possess  a  certain  degree  of  soft- 
ness, so  as  not  to  hurt  the  diseased  surface  mechanically.  3.  For  the 
same  reason  their  shape  should  be  without  corners.  4.  Their  flavor 
should  be  agreeable,  or  as  little  distasteful  as  possible.  5.  They  should 
keep  without  change  for  an  indefinite  period,  as  they  cannot  be  advan- 
tageously made  in  small  quantities. 

The  lozenges  of  the  British  Pharmacopoeia  are  most  defective,  on  ac- 
count of  their  hardness.  They  irritate  the  mucous  surface  ;  and  the  sharp 
corners  of  some  shapes  in  common  use,  or  of  the  broken  pieces  of  others, 
may  enlarge  ulcers,  tear  congested  membrane,  or  do  other  injury.     Of 


304  THERAPEUTICS    OF   THE    RESPIRATORY    PASSAGES. 

course,  when  used  for  their  constitutional  effect  these  objections  may 
scarcely  apply.  A  softer  consistence  has  been  attained  by  the  employ- 
ment of  fruit-paste — as  in  the  favorite  black-currant  lozenges ;  and  this 
substance  has  been  more  extensively  used  of  late  years.  Extract  of 
liquorice,  as  in  "  Pontefract  cakes  "  and  gelatine,  have  also  been  utilized. 
A  more  recent  innovation  is  the  effervescent  base  introduced  by  Mr. 
Cooper,  which,  for  some  purposes,  is  of  special  value.  The  French,  so 
famous  for  all  kinds  of  confectionery,  have  given  us  tlie  pdte  de  Gui- 
inauve  /  but  the  defect  of  this  is  that  it  does  not  keep  well.  We  owe  to 
them  also  our  best  jujubes,  a  sweetmeat  first  made  with  the  juice  of 
the  Hhamnus  zizyphus,  but  now  never  containing  that  agreeable 
fruit.  Experimental  experience,  extending  over  more  than  a  quarter 
of  a  century,  leads  me  to  conclude  that  a  7>a<e  de  jujuhe  of  the  best 
French  method  of  manufacture  will  be  found  most  generally  useful  as 
a  base.  It  fulfils  all  the  indications  required  ;  it  can  be  variously  fla- 
vored and  colored,  divided  into  lozenges  of  any  size  or  shape,  and  medi- 
cated with  the  most  suitable  remedies.  It  does  not  excite  nausea  or 
cause  indigestion,  and  does  not  change  too  much  after  months  of  ex- 
posure. It  is,  therefore,  adapted  for  lozenges  prescribed  for  their  topical 
influence,  and  is  equally  available  for  those  given  for  their  effects  on  the 
system. 

Lozenges  are  more  extensively  used  than  could  have  been  supposed 
when  the  London  and  Dublin  Pharmacopoeias  rejected  them.  Every  one 
who  remembers  that  time  will  know  that,  in  spite  of  that  discouragement, 
every  large  pharmacy  was  obliged  to  keep  a  considerable  number.  A 
list  of  upward  of  one  hundred  and  fifty  tried  formulre  in  use  at  that  date 
lies  before  me.  It  comprises  nearly  all  in  common  use  now.  Rhatany, 
an  excellent  astringent,  still  extensively  prescribed  for  local  purposes,  is 
in  that  list,  and  was  known  long  before.  So  with  cubeb  lozenges,  which 
have  lately  been  forced  into  extensive  sale  by  a  vendor  who  vaunts  them 
as  "bronchial  troches."  But  this  is  according  to  the  common  practice  of 
quacks,  who  take  some  of  our  tried  formulse  and  advertise  them  as  their 
own  discoveries.  We  have,  in  fact,  few  new  lozenges.  Red  gum  has 
been  introduced  ;  so,  too,  has  carbolic  acid  ;  chlorodyne  can  scarcely  be 
counted,  being  only  morphia  disguised  ;  superior  glycerine  jujubes  may 
be  had  at  any  leading  pharmacy,  or  of  inferior  quality  as  an  advertised 
panacea.  The  lozenges  comprised  in  this  long  list  may  be  classified  ac- 
cording to  their  therapeutical  uses,  e.g.,  astringents,  demulcents,  seda- 
tives, special  stimulants,  etc.  The  lozenges  made  from  my  formulae  by 
Messrs.  Allen  &  Hanburys,  have  been  generally  pronounced  a  distinct 
advance  in  medicated  lozenges,  since  after  a  long  trial  they  were  exhib- 
ited at  the  Cambridge  meeting  of  the  British  Medical  Association  a  few 
years  ago. 

As  the  words  trochisci  and  tabellcB  have  become  associated  with  the 


TOPICAL    PNEUMATICS.  305 

harder  lozenges,  as  jujubes  seem  to  savor  too  much  of  sweetmeats,  and 
as  these  are  distinct!}'  medicinal  agents,  they  were  named  pastils,  an  old 
English  word  more  familiar  in  the  French  pastilles,  and  derived  from  the 
Y^-aXm  pastillus,  which  was  used  by  Celsus  for  such  a  purpose  ;  pastllli 
will,  therefore,  be  an  appropriate  name  in  prescriptions. 

With  regard  to  dosage,  those  pastilles  which  are  intended  to  replace 
the  British  Pharmacopceia  lozenges  have  been  made  of  similar  strength, 
as  it  was  considered  advisable  not  to  burden  the  prescriber's  memory  too 
much.  This  is  specially  the  case  with  the  pastilles  of  morphia,  of  mor- 
phia and  ipecacuanha,  and  of  opium  ;  in  each  of  these  the  pastille  may 
be  regarded  as  an  agreeable  substitute  for  the  lozenge.  So,  too,  with 
the  simple  ipecacuanha  pastille,  which  will  be  found  much  more  popular 
with  children  than  the  lozenge.  The  same  remark  applies  to  pastilli  ferri. 
Each  pastillus  aconiti  may  be  considered  equivalent  to  half  a  minim  of 
British  Pharmacopoeia  tincture,  and  prescribed  accordingly.  The  pastil- 
lus expectorans,  or  morphijB  et  ipecacuanhjecompositus,  is  a  combination 
of  the  simple  one  with  other  expectorants,  and  will  be  found  most  ser- 
viceable in  bronchitis,  chronic  coughs,  etc.  The  chlorate  of  potash  pas- 
tilles are  not  so  strong  as  the  lozenges,  and  may  be  taken  in  twice  the 
usual  doses  ;  they  are,  however,  very  efficacious,  and  the  disagreeable 
flavor  is  so  successfully  concealed  that  few  can  detect  it.  If  large  quan- 
tities are  needed,  other  modes  of  administration  may  be  tried,  such,  e.g., 
as  the  compressed  tablets.  The  pastillus  sodje  chloratis  I  introduced  as 
an  efficacious  and  pleasant  substitute  for  the  potash  salt.  The  lithia 
pastille  contains  a  grain  of  the  carbonate,  and  is  valuable  for  both  its 
local  and  remote  effects.  Tlie  bcnzoated  pastille  will  be  found  the  most 
agreeable  of  all  mild  voice-lozenges,  and  may  be  taken  shortly  before 
speaking,  reading,  singing,  preaching,  etc.,  to  give  tone  to  the  vocal 
apparatus.  In  obstinate  or  chronic  cases  the  camphorated  pastille  is  a 
still  more  powerful  voice-lozenge,  but,  unfortunately,  its  flavor  is  not 
nearly  so  agreeable.  This  is,  in  fact,  the  only  one  of  the  series  that  can 
be  considered  unpalatable. 

Powders. — Solids  reduced  to  fine  powder  may  be  applied  to  various 
parts  of  the  upper  portion  of  the  respiratory  passages  by  means  of  in- 
sufflators, or  by  still  simpler  forms  of  apparatus.  A  tube  of  conven- 
ient shape,  with  a  common  puff-ball  attached,  is  an  efficient  instrument, 
only  requiring  a  little  management.  Such  a  tube  may  be  of  silver,  vul- 
canite, or  glass,  according  to  its  destined  use.  A  little  more  complicated 
contrivance  is  the  wash-bottle  we  have  all  used  in  the  laboratory.  Any 
one  who  can  bend  a  glass  tube  over  a  lamp  can  himself  make  such  an  in- 
strument of  any  size  he  likes.  A  one-ounce  or  two-ounce  phial  will  be 
convenient,  and  the  distal  end  of  the  tube  should  be  drawn  to  a  smooth 
point,  as  in  (Fig.  23).  A  puff-ball,  or  the  bellows  of  the  atomizer  com- 
pletes the  apparatus,  and  when  a  little  powder  is  put  into  the  bottle  it 
20 


•306 


THERAPEUTICS    OF   THE   RESPIRATORY    PASSAGES. 


affords  a  simple  means  of  projecting  some  of  tlie  drug*  on  any  easily  acces- 
sible point  of  the  surface. 

The  therapeutic  action  of  powders  thus  used  is  somewhat  complex. 
An  insoluble  substance  applied  in  this  manner  to  a  healthy  portion  of 
mucous  membrane  provokes  some  irritation  and  increased  secretion;  tlie 
mucus  thrown  out  envelops  the  powder  and  it  is  soon  removed.  In  mor- 
bid conditions  the  result  will  be  modified  ;  soluble  powders  will  be  to 
some  extent  dissolved  in  the  secretion,  and  thus  we  have  superadded  the 
effects  of  a  solution  of  the  substance.  Besides  the  shock  of  the  impact, 
whicli  in  some  parts  is  particularly  to  be  considered,  and   the    irritation 


occasioned  by  a  cloud  of  powder  when  that  passes  into  the  larynx,  or 
nares,  we  have  to  consider  the  therapeutical  qualities  of  the  remedy — 
astringent,  absorbent,  anodyne,  stimulant,  caustic,  special  stimulant,  etc. 
This  is  not  a  suitable  way  of  applying  caustics,  but  the  other  classes 
are  well  represented.  Tannin  and  gallic  acid  are  favorite  astringents  ; 
bismuth  and  zinc  oxide,  absorbents  ;  morphia  is  perhaps  the  most  fre- 
quently used  anodyne.  Calomel,  chlorate  of  potash,  bora^x,  alum,  and 
many  other  powders  may  be  thus  employed.  Excellent  results  are  ob- 
tainable from  the  use  of  iodoform  by  this  method.  This  and  other 
drugs  are  often  mixed  with  inert  powders  with  advantage.  Starch  an- 
swers well,  as   it   adheres  easily  to   the  moist    surface.       The  author  is 


TOPICAL    PNEUMATICS.  307 

desirous  of  again  urging  the  value  of  iodoform  by  this  method.  He 
believes  he  was  the  first  to  employ  it  thus,  and  his  experience  proves  it 
to  be  most  valuable.  Those  who  have  watched  the  remarkable  influ- 
ence of  this  remedy  when  dusted  on  other  surfaces  will  not  be  surprised 
at  its  effect  here.  In  regard  to  powders  used  in  this  way  it  must  not 
be  forgotten  that  tlie  remedy  finds  its  way  to  the  stomach,  and  therefore 
its  action  on  that  organ  and  on  the  system  must  not  be  forgotten.  When 
it  is  desirable  to  apply  powders  to  the  interior  of  the  larynx  a  weil-made 
insufflator  should  be  used,  and  the  application  is  to  be  made  with  the  aid 
of  the  laryngoscope. 

Caustics. — Sometimes  it  is  desirable  to  use  solid  caustics  in  the  mouth 
or  throat.  Here  aluminium  wire  or  glass  rod,  with  a  little  of  the  caustic 
fused  on  it,  may  be  used.  An  instrument  of  this  kind  is  much  safer  than 
ordinary  caustic-holders,  which  have  given  rise  to  accidents,  from  the 
caustic  breaking  off  and  being  swallowed.  It  should  be  added  that  caus- 
tics are  often  resorted  to  unnecessarily,  and  therefore  not  seldom  injuri- 
ously. 


INDEX. 


Acids  which  best  serve  in  artificial  diges- 
tion, 34 
Aconite,  accidental  poisoning,  178 

and  veratria  as  depressants  of  the  re- 
spiratory centre,  274 

contrasted   with  veratrum  in  effects, 
182 

effect  of  medicinal  doses,  179,  183 

effect  on  dogs,  17S 

effect  on  secretion,  182 

effect  on  the  alimentary  system,  182 

effect  on  the  circulation,  180 

effect  on  the  muscular  system,  1 81 

effect  on  the  nervous  system,  181 

effect  on  the  respiratory  system,  181 

history  of  its  use,  177 

in  acute  bronchitis,  184 

in  acute  pueumouia,  185 

in  asthma,  185 

in  catarrh  of  the  upper  air-passages, 
184 

in  pleurisy,  185 

in  tonsillitis,  184 

overdose  of,  180 

tincture  of  the  root,  185 

various  methods  of  administeriug,  184 
Aids  to  digestion,  74 

ancient  use  of  liquids  taken  from  the 
stomachs  of  animals,  74 

extract  of  malt,  74 

pepsin  and  pancreatin,  75 
Albuminate  of  mercury  fatal  to  bacteria, 

250 
Albuminates,  22 
Alcohol,  97 

administered  with  food,  lOfi 

amount  a  strong  man  can  oxidize,  99 

as  an  antipyretic,  100-104 

as  a  diaphoretic,  103-134 

as  a  nutrient,  97 

effect  in  the  stomach,  101 

effect  on  temperature,  103 

effect  on  the  blood,  101 

effect  on  the  cutaneous  system,  103 

effect  on  the  general  system,  98 

effect  on  the  heart  and  vessels,  101 

effect  on  the  liver,  102 

effect  on  the  mucous  membrane,  100 


Alcohol,  effect  on  the  nervous  system,  102 

effect  on  the  respiratory  system,  102 

in  excessive  quantity,  100 

in  phthisis,  105 

in  pneumonia,  105 

therapeutic  uses,  103 

time  required  for  elimination,  100 
Aliment  unsuitable  for  the  tissues,  9 
Aliments  as  remedies,  44 
Alkalies  to  promote  bronchial  secretion, 

239 
Alkaloid  aconitia,  186 
Alterant  expectorants,  239 
Ammonia  and  its  carbonate  as  stimulant 
expectorants,  224 

a  stimulant  of  the  respiratory  centre, 
2G5 

as  a  volatile  stimulant,  224 
Ammoniacum,  as  a  stimulant  expectorant, 
234 

effect  on  the  respiratory  membrane, 
234 

history  of.  234. 
Ammonium  chloride,  effect  on  the  system 
of,  242 

history  of,  241 
Amounts    of    digestive     fluids     secreted 

daily,  33 
Amyl  nitrite,  as  an  inh,alatiou,  250 

effect  on  the  circulation,  257 
Anaemia,  60 
Analeptics,  48 

Animal  and  vegetable  diet,  26 
Anodyne  inhalations,  295 
Antagonism  of  neurotics,  205 
Antimony  in  respiratory  diseases,  129-i;*2 

in  pneumonia,  bronchitis,  and  croup, 
132 

its  effect  on  the  system,  131 
Antiphlogistic  depletion  as  a  remedy,  1(.9 

diet  and  regimen,  108 

use  of  mercury,  125 
Antiphlogistics,  107 
Antipyretic,  quinine,  156 

.treatment  in  pneumonia,  150-153 
Antipyretics,  142 

cold  affusions,  cold  packs,  cold  spong- 
ing, 154 


310 


INDEX. 


Antipyretics,  cold  first  of  the  direct,  142 
Antiseptic  action  of  quinine,  15!j 

and  disinfectant  pneumatics,  249 

expectorants,  253 

remedies,  uses  in  respiratory  diseases, 
250 
Antiseptics,  history  of,  249 

through  inhalation,  297 
Antispasmodic  pneumatics,  255 

pneumatics  contrasted  with  expecto- 
rants, 255 
Apnoea,  20 
Apomorphia,  as  an  expectorant,  220-223 

as  a  spray  in  phthisis,  221 

injected  into  the  veins  of  animals,  129 

in  respiratory  diseases,  129 
Arsenic,  as  an  anti-malarial,  160 
Arteriotomy,  110 
Assafoetida,  as  an  expectorant.  235 

effect  on  the  bronchial  secretions,  23G 

effect  on  the  system,  235 
Assimilation  of  food,  4 
Asthma,  relief  from  nitrites,  ethyl-iodide, 

etc.,  259 
Astringents,  as  contra-expectorants,  263 

used  in  atomizers,  296 
Atomizer  with  tube,  291 
Atomizers,  illustrated.  288 

solutions  of  metallic  salts  in,  296 
Atropia  and  aconite,  antagonism  of,  204 

and  bromal,  antagonism  of,  2(J4 

administered  for  opium-poisoning,  193 

counter-poison  to  morphia,  193 

and  physostigraa,  antagonism  of.  208 

and  pilocarpine,  antagonism  of,  203 

as  an  expectorant,  2'21 

and  prussic  acid,  antagonism  of,  204 

effect  in  j^hthisis,  200 

effect  on  circulatory  system,  195 

effect  on  the  gland-cells,  198 

elimination  of,  lUG 

with  iodine,  246 

Bacterium  subtile,  251 

Balance  between  food  supply  and  power  of 

the  system,  44 
Balm  of  Gilead,  234 
Balsam  of  Tolu  in  chronic  coughs,  232 
Balsams  as  expectorants.  231 
Barth's  oxygen  inhaler,  284 
Baths  for  typhoid.  148 

quinine  and  salicylate  of  soda  as  an- 
tipyretics, 143 
Bdellium,  234 
Beef-tea  as  a  nutrient,  46 
Belladonna  and   aconite  in  laryngeal   ca- 
tarrh, 199 
and  atropia,  193 

and  atropia  as  stimulants  of  the  respi- 
ratory centre,  265 
as  an  antispasmodic,  197 
as  a  respiratory  and  cardiac  stimulant, 

198 
effect  in  asthma,  199 
effect  in  ciiphtheiia,  200 


Belladonna,  effect  in  influenza  or  catarrhal 
fever,  199 

effect  in  larj'ngismus,  200 

effect  of  excessive  doses,  194 

effect  on  the  ej-e,  196 

effect  on  the  glandular  system,  196 

effect  on  the  muscular  system,  196 

effect  on  the  respiration,  195 

effect  on  temperature,  19(5 

moderate  doses  of,  194 

or  atropia,  effect  on  the  nervous  sys- 
tem, 195 

or  atropine  to  relieve  jjain,  197 

with  opium,  201 
Benzoin,  effect  on  the  mucous  membrane, 

232 
Bergson's  atomizer,  287 
Beverages,  b9 

fermented,  tea  and  its  allies,  90 

simple  diluents,  mucilaginous,  saccha- 
rine,  liquid    foods,   aerated    drinks, 
acidulous  drinks,  salines,  medicinal 
beverages,  89 
Bile,  37 

as  an  aid  to  digestion,  76 

as  a  medicinal  agent,  76 
Bleeding  carried  to  excess,  113 

history  of,  109 

for  pneumonia,  115 

for  undue  blood-pressure  in  acute  dis- 
eases, 116 

in  distention  of  the  right  heart,  116 

in  respiratory  diseases,  110 

present  view  of  it  as  a  remedy,  115 

reaction  to  stimulation,  113 
Blisters   in   chronic    sj-novitis  and   acute 
rheumatism,  119 

in  thoracic  di.seases,  118 

pustulants,  issues  and  moxa,  118 
Blood  too  oxygenated,  20 

too  venous,  20 
Bromides  as  antispasmodics,  269 

depress  the  respiratory  centre,  2G8 

effect  on  the  respiratory  system,  209 

elimination  of,  268 

in  combination  with  other  medicines, 
270 

value  of  the  different  comiiounds,  271 
Bronchial  secretion  hindered,  214 

troches,  304 
Brown-Sequard    and     others     on    nerve- 
centres,  19 
Bunistead's  vaporizer,  283 

Caffeine   and   morphia,  antagonism   of, 

205 
Camphor  and  iodine  inhaled,  243 

as  an  expectorant,  207 

effect  on  the   system,  especially   the 
mucous  membrane,  231 

effect  in  bronchitis,  207 

effect  on  the  system,  207 
Canada  balsam  as  an  expectorant,  231 
Calcium  phosphate,  04 

amour.t  in  the  body,  64 


INDEX. 


311 


Calcium  phosphate,  effect  of  excluding  it, 

6-5 
Calomel  and  opium,  133 
Carbo-hydrates  or  amyloids,  23 
Carbolic  acid,  history  of,  254 
Carbonate  of  ammonia  as  an  expectorant, 

225 
Cases  of  antipyretic  treatment  in  the  Ger- 
man hosiiitals,  153 
Catarrhal  pneumonia,  Ifio 
Caustic,  safest  method  of  applying  it,  307 
Central  pneumatics,  263 
Chemical  daily  needs  of  the  tissues,  25 
Cherry-laurel,  its  use,  273 
Chinoliu  or  quinolin,  174 
Chloral  as  a  depressant  of  the  respiratory 

centre,  2(i7 
Chlorate  of  potash  as  an  alterant   expec- 
torant, 240 

effect  on  the  mucous  membrane,  241 

effect  on  the  system,  240 
Chloride  of  sodium  in  food,  24 
Chloroform,  effect  on  the  respiratory  mem- 
brane, 2G0 
Chlorosis,  use  of  iron  in,  61 
Codeia,  193 
Cod4iver  oil  analyzed,  49 

best  methods  of  administering  it,  51 

history  of  its  use,  48 

in  dinjestion,  50 

in  phthisis,  50 

with  ether,  52 
Coffee,  its  effects,  90 
Cold  affusions  as  an  antipyretic,  154 

as  an  antipyretic,  145 

bath  treatment  to  check  heat-produc- 
tion, 143 

baths,  in  diphtheria,  152;  in  pneu- 
monia, 149  ;  in  scarlet-fever,  152  ; 
in  typhoid,  contra  indications,  149 

by  sprays,  as  an  anti^Dyretic,  155 

drinks  as  antipyretics,  155 

enemata,  as  antipyretics,  150 

history  of  its  internal  and  external 
use,  145 

in  acute  rheumatism,  148 

in  typhoid,  147 

locally  applied  as  an  antipyretic,  155 

packs  as  an  antipyretic,  154 

sponging  as  an  antipyretic,  154 

treatment,    various    opinions    of    its 
value,  158 
Comparative  value  of  different  diets,  30 
Conia  as  an  inhalation,  275 

best  preparation  to  use  of,  275 

or    conine.  effect    on    the  respiratory 
centre,  274 
Coaium,  274 

Contra-expectorants,  203 
Co{)aiba,  237 

Corrosive  sublimate  fatal  to  bacteria,  250 
Counter-irritation,  117, 

blisters,  pustulants,  issues,  and  moxa, 
118 

cupping,  foot-baths,  etc.,  117 


Counter-irritation,  hot  water,  117 

its  effects,  118 

poultices  and  fomentations,  117 
Cough,  a  natural  relief,  214 

with  no  secretiou,  214 
Creasote,  254 
Croup-kettle,  284 

Croupous    pneumonia    treated   with   cold 
baths,  147 

use  of  quinine,  104 
Cubeb,  253 

lozenges,  304 
Cuca  analyzed,  93 

as  a  beverage,  93 

as  a  stiumulant,  92 
Cucaine  as  a  nerve  food,  93 
Cyanide  of  potassium,  safe  dose,  273 
Cyanosis,  lii 

Denutriexts,  107 
Depressant  expectorants,  233 

antimony  and  ipecacuanha,  222 
Depressants  of  the  respiratory  centre,  206 
Deprivation  of  amyloids,  41 

of  proteids,  41 
Destruction  of  tissue,  excessive  rapidity  of, 

7 
Dextrin,  23 
Diaphoretics,  jaborandi,  138 

opium,  jaborandi  and  its  alkaloid,  pil- 
ocarpine, 134 

spirits  of  nitre  and  liquor  ammoniai 
acetatis,  138 

their  action,  133-135 

Turkish  bath,  135 
Digestion  disturbed  through  deficiency  of 
food, 41 ;  through  excess  of  food  40  ; 
through  the  quality  of  the  food,  41 

of  iron,  50 
Digestive  process  disturbed  by  the  body, 

40 
Diminution  of  iron  in  the  system,  GO 
Digitalis     as     an    antipyretic,     175  ;     in 
phthisis,  165 

in  bronchitis,  176 

in  hsemoptysis,  176 

in  phthisis,  176 

in  pneumonia,  175 
Diphtheria,  cold  bath  treatment,  152 
Disinfectants,  history  of,  249 
Dried  blood  as  a  nutrient,  77 

foods,  24 
Double-valved  inhaler,  285 
Dover's  powder,  190,  191 
Dyspnoea,  20 

Effects  of  change  of  external  tempera- 
ture, 142 

of  cura  on  fatigue,  93 

of  counter-irritation,  118 
Eggs  as  nutrients,  47 
Emetics,  128 

antimony,  128 

effects  on  the  system,  128 


312 


INDEX. 


Emetics,  in  croup,  diphtheria,  and  bron- 
chitis, 130 
Elastic  gases  set  free  in  a  patient's  room, 

282 
Elemi  as  an  ointment,  237 
Errhines,  effect  on  the  respiratory  mem- 
branes, 213 
Essential  oils  analyzed,  230 
as  expectorants,  230 
elimination  of,  231 

effect  on  the  alimentaiy  membrane, 

230 

Ether  and  chloroform  as  antispasmodics, 

2(j0  ;     compared     in   their    effects, 

261 ;  effect  on  the  circulation,  2G0 

effect  on   the   respiratory  membrane, 

2G0 
effects  on  the  system,  54 
in  digestion,  52 

methods  of   administering  in  dose,  54 
ordinary  dose,  55 
Ethyl-iodide,  245 

or  hydriodic-ether  as  an  antispasmod- 
ic. 2G0 
Evacuants,  119 

Excessive  amount  of  liquid  drunk.  86 
Excretions  from  cold  bath  treatment,  143 
Exercise  and  rest,  04 

its  effect  on  the  general  system,  96 
Expectorants,  213 

action  of  different  remedies  as,  215 
which  affect  the  quantity  of  sputa  se- 
creted, 215 
which  diminish  the  secretion,  216 
Expectoration  in  health,  214 
Experiments  on  the  secretion  of  mucus  m 

animals,  217 
External  heat  as  a  diaphoretic,  134 
Extract  of  malt  as  an  aid  to  digestion,  74 

Farinaceous  and  saccharine  nutrients,  47 
Fats  in  digestion.  23,  37,  39 

or  hydrocarbons,  23 
Fatty  nutrients,  47 
Feeding  by  the  nose  or  rectum,  77 
Fetid  gum  resins,  235 
Fomentations,  117 
Food  and  diet,  21 

introduced  through  a  fistulous  wound, 
38 

of  a  invalid,  42 
Forced  feeding  by  the  stomach,  77 
Formic  acid  fatal  to  bacterium  subtile,  251 
Free  phosphorus,  G8 

as  a  nutrient,  70 
Function  of  respiration,  14 

Galbanum  as  an  expectorant,  236 
Gargles,    alum,    chloride    of     aluminium, 
tannin,  borax,  as  astringents,  300 
astringents,    disinfectants,    and   anti- 
septics as,  300 
Condy's  fluid,  carbolic  acid,  as   disin- 
fectants. 301 
of  lactic  acid,  301 


Gargles,  their  use,  298 
Gargliug,  the  act  of,  298 
I  Gas  in  the  stomach,  35,  40 
Gastric  juice,  34 

ancient  artificial  use  to  aid  digestion. 
74 
Gelatinoids,  22 
General  expectorants,  2,'2 
Glandular  system  of  the  respiratory  tract 

211 
Gout  from  habitual  excess  of  food,  41 
Grape  cure,  47 
Gum  resins,  history  of,  233 

Habitual  excess  of  food,  41 
Hiematinic  effects  of  iron.  59 
Haemoglobin  as  the  purveyor  of  oxygen,  15 
Hemorrhages,  iron  used  as  a  spray,  62 
Hot  water  as  a  medicine,  88 
Hunter's  inhaler,  286 
Hydrocyanic  acid,  chief  use  of,  273 

in  whooping-cough,  273 
Hydropathy-,  88-145. 
Hyoscyamus  and  stramonium,  206 

effect  on  the  respiratory  organs,  206 
Hyi)odermic  injection  of  blood  and  food. 
83 

of  milk,  84 
Hypophosphites,  72 

use   in   Xorth   London    Consumption 
Hospital,  73 

Idiopathic  anaemia,  60 

ludol,  36 

Ingredients  of  milk,  21 

Inhaling  solutions  from  a  bottle.  296 

Inhalation  chamber  at  San  Remo,  283 

of  camphor,  295 

of  carbonic  acid,  278 

of  ehlorine,  280 

of  fumes  of  sulphur,  280 

of  fumes  of  tar,  279 

of  iodine,  280 

of  steam,  294 

of  steam  with  hops,  and  many  aromat- 
ic sedatives,  295 

of  stimulants,  295 

of  vapor  chlori.  vapor  of  iodi,  295 

rooms  at  mineral  spas,  281 
Inhaler-respirator,  292 
Inhalers  illustrated,  283 
Injections  into  serous  cavities,  82 

into  the  peritoneum,  82 
Inorganic  sub-stances  in  food,  24 
Inula  helenium,  effect  on  the  system,  237 
Ipecacuanha,  its  effect  on  the  system,  i;,2 

in  respiratory  diseases,  129-132 
Iron,  56 

and  manganese  in  the  blood,  25 

as  a  nutrient,  57 

best  given  with  food,  62 

effect  on  the  pulse.  58 

in  bronchial  affections,  63 

increasing  oxidation,  58 


INDEX. 


313 


Iron,  quantity  assimilated  and  eliminated, 
(JO 

supplied  to  the  blood,  12 

used  in  hemorrhages,  03 

use  of,  in  chlorosis,  01 

with  the  red  corpuscles,  57 
Irrigation  of  the  nasal  passage,  302 
Irregular  secretion  of  bile,  '37 
Iodide  of  iron  in  phthisis,  03 
Iodide  of   potassium  as   an   expectorant, 
219 

sprays  for  asthma,  245 
Iodine,  antispasmodic  expectorant,  245 

as  an  alterative  expectorant,  24o 

as  an  expectorr.nt,  244 

effect  on  the  system,  243 

excreted.  244 

inhaler,  285 

in  pneumonia,  247 

in  phthisis,  246 

in  syphilis,  246 

its  use  in  respiratory  diseases,  246 

stimulates  the  respiratory  membrane, 
243 

susceptibility  of  patients  to,  245 

with  belladonna,  240 

with  carbolic  acid  inhaled,  243 

with  morphia,  245 
lodism,  symptoms  of,  244 
Iodoform,  applied  to  the  throat  as  a  pow- 
der, 307 


as  a  sjjray,  297 

effects  of,  248 

with     croton  - 

phthisis,  248 


Jaborandi  and  pilocarpine,  their  effect, 
138 
antagonized  by  belladonna,  140 
effect  on  the  temperature,  139 
effect  on  the  sight,  140 
in  renal  dropsy,  asthma,  pleuritic  ef- 
fusion, and  diphtheria,  140 
.Turgensen's  method  of  baths  in  pneumo- 
nia, 149 

Kairin,  an  antipyretic,  171 

history  and  uses  of,  171 

illustrations  of  its  use,  171 
Koumiss,  46 

Larix,  effect  on  the  system,  238 

Leeches,  cupping,  etc..  117 

Lee's  steam-draught  inhaler,  286 

Leucin  and  tyro-in,  30 

Liebig,  Pettenkofer  and  Voit  on  food  con- 

verued  into  tissue,  10 
Linctus,  303 

•Lobelia  and  tobacco  as  depressant  expec- 
torants, 224 
effect  on  the  system,  224 
Lozenges,  their  use,  303 
Lungs,  amount  of  air  after  a  full  inspira- 
tion, 15 


chloral  -  hydrate,      in 


Lungs,  amount  of  air  at  every  respiration, 
15 

laboied  respiration,  15 

vital  capacity  under  different  circum- 
stances, 15 

Magnesium  phosphate,  06 

amount  in  the  system,  66 
Martindale's  portable  inhaler,  286 
Mastich,  237 
Meal- times,  42 

Medicine,  influenced  by  the  digestive  or- 
gans, 11 

general  effect  in  passing  through  the 
system,  12 

regarded  as  food,  1 1 
Mercury  as  an  evacuant,  121 

effect  on  the  system,  124 

eliminated  by  the  excretions,  124 

history  of  its  u^e,  121 

in  acute  bronchitis,  126 

in  broncho-pneumonia,  126 

in  diphtheria,  126 

in  pleurisy,  128 

in  pneumonia,  125-127 

in  tonsillitis  and  in  parotitis,  126 

its  extravagant  use,  122-124 

perchloride  and  sublimate  in  diphthe- 
ria, 127 
Methods  of  inhaling,  283 

of  vaporizing  a  room,  283 
Micro-organisms,  experiments,  251 
Milk  as  a  nutrient,  46 

for  invalids,  43 
Morphia  and  atropia,  201 

and  atrophia,  neutralizing  effects  of, 
202 

salts.  192 
Mucous  ferment  in  digestion,  35 
Myrrh  in  phthisis  and  as  a  gargle,  234 

stimulant  to  the  mucous  membrane, 
233 

Narcotics,  gpneral  use  of,  187 
Nasal  douche,  301 

best  astringents  in,  301 

mode  of  employing  it,  301 
Nauseant  diaphoretics,  136 

Dover's  powder,  130 
Nauseants,  130 

antimony,   131 

as  depressants  of  the  respiratory  cen- 
tres, 200 

in  pneumonia,  bronchitis,  croup,  183 
Nerve  centres  of  perspiration,  19 
Nervous  control  of  nutrition,  10 
Neurotics,  187 
Newman's  atomizer.  289 
Nitrate  of  silver,  application  of,  220 
Nitrite  of  amyl,  in  angina  pectoris,  358 

in  asthma,  258 

its  effect,  137 

of  sodium,  effect  on  the  circulation, 
259 
Nitrogen,  22 


314 


INDEX. 


Xitrogenous  diet,  2S 

plastic  or  albuminous  foods,  23 
Nitro-glycerine,  dose  of,  2ol) 

in  angina  pectoris,  asthma,  whooping- 
cough,  etc.,  259 
Noeud  vital,  19 
Non-nitrogenous  foods.  23 
Nutrients  as  promoteis  of  construction,  45 

beef  tea,  46 

buttermilk,  46 

milk,  40 
Nutrition   in   relation   to   respiratory  dis- 
eases, 11 

in  relation  to  therapeutics,  3 

from  atmospheric  oxygen,  3 

too  abundant  supply  of,  8 
Nutritive  value  of  foods,  26 
Nux  vomica  and  strj-chnia  stimulants  of 
the  respiratory  centre,  205 

Oil  of  anise,  effect  on  the  mucous  mem- 
brane, 2ol 
of  eucalyptus  as  a  stimulant  expecto- 
rant, 'Sii 
Opium  and  aconite,  193 
and  bromide,  193 
and  chloral  hydrate,  193 
de:ith  from,  is9 
effect  of  a  small  dose,  188 
effect  on  children  and   extreme  age, 

192 
effect  on  the  respiratory  centre,  364- 

267 
in    coryza,    influenza,    asthma,    and 

bronchitis,  190 
toxic  dose  of,  188 
Opoponax.  as  an  expectorant,  237 
Ordinary  condiments  as  stimulants  to  di- 
gestion, 78 
Oxidation  explained,  16 
in  life  and  death,  0 
in  tlie  tissues,  not  in  the  blood,  16 
Oxygen,  effects  of,  absence  of,  18 

inhalers,  284 
Oxygenation  impeded  or  arrested,  17 

Panckkatic  juice,  36 
Pancreatin,  the  best  method  of  adminis- 
tering it,  70 
Pancreatized  foods,  76 
Parasite,  origin  of  disease,  250 
Pastilles,  305 

of  morphia,  etc.,  305 
Pate  de  jujube,  304 
Pepsin,  34 

action  of,  35 

and  pancreatin  as  aids  to  digestion, 
75 

prejinred  with  salt,  75 
Peptonized  foods.  76 
Perchloride  in  blood-poisoning,  62 

in  diphtheria.  63 

in  phthisis,  63 

in  scarlet  fever,  63 

of  iron,  63 


Pilocarpine  and  emctia   as   expectorants, 
j  220 

I  in  diphtheria  and  phthisis,  140 

Phosphate  of  lime,  65 
1  best  method  of  administering,  66 

in  ana?mia,  66 
i  used  in  rickets,  65 

Phosphates  eliminated   in  bronchitis  and 
phthisis,  67 

in  food,  25 
Phosphorus  and  its  compounds,  64 

as  a  stimulant  in  the  exhaustion  of 
fever,  71 

best  method  of  administering  it,  73 

free,  its  use  and  elimination,  68 

in  diseases  of  the  nervous  .system,  71 

in  phthisis,  73 

in  pneumonia,  71 

its  action  on  the  system,  68-70 

its  use  in  diseases  of  the  osseous  sys- 
tem, 71 
Phthisis,  quinine  as  an  antipjretic,  105 
Physostigma,  274 
Pneumatics,  207 

Pneumonia,  cardiac  failure  and  its  treat- 
ment, 151 

cold  effusions,  154 

treated  with   cold   baths   and   stimu- 
lant^s,  150 

use  of  c-timulants,  151 

various  treatments,  165 
Potash,  as  an  expectorant,  219 
Potassium    phosjjhate,  action  on  the  sys- 
tem, 68 
Powders  applied   to  the  respiratory   pas- 
sages. 305 

how  best    api^lied   to    the  respiratory 
organs,  306 
Preparation  of  food  stuffs,  33 
Prepared  foods  to  be  introduced  per  rec- 
tum. 77 
Prussic  acid,  effect  of  an  officinal  dose,  273 

effect  on  the  blood  and  respiration,  271 
Ptyalin,  33 

Purgation,  its  use,  119 
Purgatives,  119 

drastics,  120 

mild  aperients,  120 

saline  laxatives,  120 
Pyrexia  fi'om  septic  conditions,  144 

its  causes,  144 

Quebracho  as  an  antispasmodic,  201 

dose  given  of,  2(;3 
Quinia,  effect  on  the  excretions.  143 
Quinine  and  cold  baths,  153-163 

as  an  antipyretic,  157 

eff'-ct  on  the  blood,  157 

effect  on  the  heart,  101 

effect  on  the  nervous  system,  161         • 

effect  on  the  sy.stem,  157 

elimination  of,  101 

in  acute  rheumatism,  163 

in  catarrhal  pneumonia,  165 

in  croupous  pneumonia,  164 


INDEX. 


315 


Quinine  in  hay-fever,  164 
in  pneumonia.  152 
in  phthisis,  1G5 
in  whooping-cough,  1G4 
its  action,  144 
its  antiseptic  action,  159 
large  doses,  101,  1G2 
power  of  destroying  micro-organisms, 

160-164 
power  over  fever  heat,  162 

Rapid  rubefacients  and  vesicants,  119 
Relative  proportions  of  food  at  different 

meals,  42 
Remedies  in  accumulated  secretion  of  the 

bronchial  tubes,  215 
Rennet  in  digestion,  35 
Resorcin,  174 
Respiration,  14 

controlled  by  the  nervous  centres,  211 

during  balloon  ascension,  17 

affected  by  the  quality  of  the  air,  2C9 

effects  from  varied  altitudes,  17 

in  mines,  diving-bells,  etc.,  17 

labored,  15 

more   active    when    arterialization   is 

defective,  19 
number  required  to  renew  the  air  in 

the  lungs,  16 
performed  by  the  skin,  18 
Respirators,  292 

their  use,  293 
Respiratory  centre  of  nerve  action,  19 
Rest  as  an  antijjhlogistic  agent,  1U8 

as  a  first  remedy  in    respiratory  dis- 
eases, 95 
promotes  nutrition,  95 
Rickets,  65 

Rossbach's    experiments  on    secretion    of 
mucus,  217 

Sagapenum,  effect  on  the  respiratory  and 

alimentary  mucous  membrane,  236 
Saliciu,  antipyretic  and  antiseptic,  168 

as  an  antipyretic,  its  history,  166 

as  a  substitute  for  quinine,  167 
Salicyl  compounds,  166 
Salicylate  of  soda,  its  use,  169 
Salicylates,  effect  on  the  stomach,  168 
Salicylic  acid  an  antiseptic,  168 

best  method  of  administering  it,  170 

its  action,  163 
Salicyls  as  antiseptics    and   disinfectants, 
169 

effect  on  the  blood,  169 

effect  on  temperature,  169 

in  acute  rheumatism,  170 

in  diphtheria  and  scarlet  fever,  170 

in  pneumonia,  170 

process  of   elimination,  169 
Saline  diaphoretic,  mindererus'  spirit,  136 

diaphoretics,  136 
Saliva,  33 
Salts,  24 

as  nutrients,  48 


Salts  of  lithia  as  an  expectorant,  219 
Scarlet  fever,  cold  bath  treatment,  152 
Scheele's  acid,  272 
Schnitzler's  atomizer,  288 
Scilla  as  an  expectorant,  225 

its  effect  on  the  mucous  membrane,  226 
Secretion  of  mucus,  effect  of  soda  on,  217 
effects  of  temperature  on,  217 
experimental  application  of  medicinal 

substances,  217 
in  the  normal  state,  217 
Petronne's   experiments  on   animals, 
218 
Sedative  and  anodyne  pneumatics,  262 
Senega  as  an  expectorant,  227 
effect  on  the  system,  227 
history  of,  327 
Sieglc's  atomizer,  290 
Simple  atomizer,  289 

inhaler,  295 
Siphon  douche,  301 
Soda,  as  an  expectorant,  219,  239 
Sodium  and  potassium  phosphate,  66 

and  potassium  phosphates,  action  on 

the  system,  67 
phosphate,  action  on  the  system,  67 
Solids  slowly  dissolved  in  the  mouth,  303 
Spirits  of  nitre,  its  effect,  137 
Spiritus  ajtheris  nitrosi,  136 
Sprays,  cold  and  warm,  296 

remedies  and  amount  required,  297 
Starvation,  8 

death  accelerated  by  a  low  tempera- 
ture, 8 
death  hastened  by   reduction  of  ex- 
ternal air,  8 
death- i)oint   four-tenths   the    normal 
weight,  8 
Steam-draught  inhaler,  284 

inhalation,   in  acute  bronchitis,   294 ; 

in  diphtheria  and  croup,  294 
inhalations,  their  use,  294 
with  hops  inhaled,  295 
Sternutatories,  213 
Stimulant  expectorants,  224 
Stimulants  of  the  respiratory  centres,  265 
of  the  respiratory  centres,  in  various 

combination,  266 
to  digestion,  78;  ordinary  condiments, 
aromatics,      carminatives,      bitters, 
general  tonics,  sedatives,  78 
Storax  as  an  expectorant,  232 
Stramonium,  effect  and  use  in  asthma.  206 
Strychnia,  for  night  sweats  of  phthisis,2(i5 
Succus  entoricus,  38 

Sulphate  of  copperas  an  emetic  in  poison- 
ing from  vapor  of  phosphorus.  69 
Sulphur,  effect  on  the  nmcous  meml^rane, 
242 
history  of,  242 
Symptoms    produced    on    respiration    by 
varied  altitudes,  17 

Table  of  food  required  for  rest  and  for 
work,  27 


316 


INDEX. 


Table  of  the  nutritive  values  of  food,  27 
Tannin,  application  to  the  larynx,  220 
Tar  and    its  deiivatives,    as    antiseptics, 

as  a  stimulant  expectorant,  2o!) 

vapor,  254 
Tea,  coffee,  etc.,  analyzed,  90 

its  effects,  91 
The  antiseptic  respirator.  293 

complete  atomizer,  291 

eclectic  inhaler.  287 

]ibaryngeal  douche  and  irrigator,  o02 
Topical  pneumatics,  270 

pneumatics,  history  of,  270 
Transfusion,  79 

history  of,  79 

of  blood  of  animals,  of  blood-serum, 
of  milk,  80 

of  blood  into  the  pleural  cavity,  82 

of  carbonate  of  auimonia,  81 

of  defibrinated  blood  into  arteries,  81 

of  saline  fluids.  80 

of  saline  fluids  into  arteries.  .'•2 
Tubercle  bacillus,  difficulty  of  destroying- 

them,  2.'32 
Turpentine   as   an  antidote  for  poisoning 
from  vapor  of  phosphorus,  09 

as  a  stimiilant  to  the   mucous   mem- 
brane, 228 

effect  of  an  overdose,  228 

oil  of,  effect  on  kidneys,  229 
Turpentines  analyzed,  229 


Uses   of    inhalations    and    other    topical 

pneumatics,  294 
Uric  acid  in  relation  to  gout,  7 


Vagi  divided,  19 

Valuable  properties  of  quinine,  IGO 
Vapor  of  phosphorus,  its  effects  in  large 
doses,  09 

of  phosphorus,  its  use,  68 
Variations  in  the  digestive  process,  39 
Vegetable  acids,  24 

diet,  28 
Venesection,  110 
Veratria  as  an  antipyretic,  174 
Vomiting  to  empty  the  air-passages,  129 

Warm  beverages  in  respiratory  diseases,  87 
\\  arm  blood  as  a  nutrient.  77 
Waste  and  repair  in  health,  4 

products,  accumulation  of,  within  the 
tissues,  7 
Water,  amount  in  the  body,  2G 

as  a  dilutant  in  the  system,  SO 

as  a  regulator  of  temperature,  87 
t       as  food,  26 

average  amount  taken  in  health,  85 

cold,  to  assist  digestion,  87 

diluents,  beverages,  85 

hot,  as  a  medicine,  88 

necessary  to  digestion,  85 

quantity  in  the  system,  80 

rapid  introduction  into  the  circulation, 
80 

removed  through  the  skin,  18 

temperature  best  suited  for  digestion, 
87 

warm,  in  painful  affections.  87 
Willow,  history  of  its  use  in  medicine.  166 
Wintrich's  atomizer,  288 

Ziemssen's  method  of  baths,  148 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


TOMB)  m 

DEC  1 4  Rtt'f 

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APR  2  6  REC'D 

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